The attribution of “human error” must mark the beginning, rather than the end, of the search for contributing factors to an adverse event, say Jonathan Cohen and Sephalie Patel
All medical departments have the ability to learn from their mistakes, thereby preventing adverse events or making them less likely to recur in the future. Unfortunately, creating a “memory” of adverse events at the departmental or organizational level is easier said than done. A 2015 study, for example, found that after a problem emerges, most healthcare practitioners “fix and forget” rather than “fix and report.”1 This is often our human instinct in the wake of a mistake, but it impedes an organization’s ability to learn and reduces patient safety to a reactive role, rather than one that proactively seeks to reduce harm.1 What can those charged with investigating incidents do then to ensure that a comprehensive approach to learning is followed?
To ensure that learning and improvement occurs from any event, incident investigation must transcend the “first story” (where human error is the cause) and seek out the “second story,” which is a deeper, richer assessment of the event.2 In order to identify more than just the superficial contributing factors involved in an adverse event, the event must be examined from several different viewpoints.3 Although hypothesizing the cause of this event may be helpful in guiding the direction of the investigation, it’s important that investigators keep an open mind so they’re not subject to cognitive biases during the process.4 Three components to consider during incident review include interviews of involved team members, simulation of the event, and creating viable strategies to avoid recurrence.
Once a cursory outline of an adverse event has been established, investigators need to interview the staff members involved.3 The interview should be loosely structured and establish a sequence of the events, as well as the thought process behind clinical decisions. Several things can make the interview process more fruitful: interviewers who have reviewed the case and familiarized themselves with the details ahead of time; individually conducted interviews (as opposed to group interviews); and the absence of the participants’ supervisor(s) at the meeting, so that candor is not impeded.5 The interviewers should use care eliciting information so as not to be judgmental, accusatory, or to ask leading or suggestive questions. A lot of information on how to best conduct these interviews can be garnered from the fields of simulation debriefing6 and crisis negotiation.7 For instance, the interviewer should avoid starting a question with the word “why” as it typically triggers a defensive response. Replacing the question “Why did you…?” with “What led you to…?” can diffuse the perception of being accused of wrongdoing.
Simulation of an adverse event has been frequently used to augment the investigative process.8 Potential benefits include the recognition of systemic (latent) causes and the identification of shifts in cognitive demands and the potential for loss of situational awareness.9 It may be difficult to simulate certain scenarios with a high degree of fidelity due to the nature of the adverse event. Another limitation is that meticulous attention must be paid to details when recreating the original scenario. For example, simulations of US Airways Flight 1549 (the “Miracle on the Hudson”) demonstrated that the accident aircraft could have safely landed at both LaGuardia and Teterboro airports, but only if the decision to land was made immediately after the bird strike. Such simulations did not take into account the time necessary for the pilots to assess the situation and develop a plan. Once a modest 35 second delay was entered into the process to account for this, more faithfully replicating what the pilots experienced, landing at either airport was unsuccessful, reinforcing the pilots’ decision to ditch the aircraft.10
Once the causative factors of the adverse event are understood, clinical teams can develop strategies to reduce the likelihood that the event will recur. These strategies must not only effectively target causative factors, they must also be sustainable. One theory of risk management, the hierarchy of intervention effectiveness, suggests that strategies focused on systems (i.e. automation & standardization) are superior to improvements focused on people (policies & training).11 Yet, although people focused strategies are traditionally lower on the hierarchy, in medicine the judgments that take place at the point of care are ultimately dependent on humans, and strategies focused on people must comprise part of the approach to reducing the likelihood of adverse event recurrence. Such approaches include lectures/morbidity and mortality conferences, problem based learning, and simulating the adverse event. The benefit of using simulation as a people focused strategy is that it allows for training of non-technical skills (such as communication, team working, and situational awareness), which contribute to the majority of errors in high risk industries, such as healthcare.12,13
Creating a medical department with a memory is a formidable task and will mean approaching adverse events differently than we have typically done before. The attribution of “human error” must mark the beginning, rather than the end, of the search for contributing factors. A complete identification of the contributing factors can only be achieved after a systematic investigation of the event. Only after this has taken place, can we begin to learn from the adverse event. Finally, learning must then result in interventions that are both effective and sustainable.
Jonathan Cohen is an associate member in the Department of Anesthesiology at Moffitt Cancer Center and serves as the patient safety officer for the department. He has a master’s degree in patient safety leadership and has been an invited speaker on the topic at national professional meetings. Twitter @JonathanCohenMD
Sephalie Patel is an associate member in the Department of Anesthesiology at Moffitt Cancer Center and is currently the director of research for the department. Her clinical interests include oncology related outcomes based research, blood management, and patient safety.
Competing interests: none declared.
- Hewitt TA, Chreim S. Fix and forget or fix and report: a qualitative study of tensions at the front line of incident reporting. BMJ Qual Saf 2015; 2:303-310.
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- AHRQ. System-Focused Event Investigation and Analysis Guide. Retrieved from https://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4-guide.html
- Rudolph JW, Simon R, Dufresne RL, Raemer DB. There’s No Such Thing as “Nonjudgmental” Debriefing: A Theory and Method for Debriefing with Good Judgment. Simul Healthc 2006; 1:49-55.
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- NTSB. (2010). Loss of Thrust in Both Engines After Encountering a Flock of Birds and Subsequent Ditching on the Hudson River, US Airways Flight 1549, Airbus A320-214, N106US, Weehowken, New Jersey, January 15, 2009. Aircraft Accident Report NTSB/AAR-10 /03. Washington, DC.
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- Flin R, O’Connor P, Crichton M. Safety at the Sharp End: A Guide to Non-technical Skills. CRC Press 2008.