{"id":50301,"date":"2021-05-21T10:29:53","date_gmt":"2021-05-21T09:29:53","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=50301"},"modified":"2021-05-26T10:57:23","modified_gmt":"2021-05-26T09:57:23","slug":"a-medical-department-with-memory-learning-from-adverse-events-so-history-doesnt-repeat-itself","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2021\/05\/21\/a-medical-department-with-memory-learning-from-adverse-events-so-history-doesnt-repeat-itself\/","title":{"rendered":"A medical department with memory: learning from adverse events so history doesn\u2019t repeat itself"},"content":{"rendered":"

The attribution of \u201chuman error\u201d must mark the beginning, rather than the end, of the search for contributing factors to an adverse event, say Jonathan Cohen and Sephalie Patel<\/span><\/p>\n

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 \u201cmemory\u201d of adverse events at the departmental or organizational level<\/span> is easier said<\/span>\u00a0than done<\/span>.<\/span> A 2015 study, for example, found that after a problem emerges, most healthcare practitioners \u201cfix and forget\u201d rather than \u201cfix and report.\u201d1<\/sup> This is often our human instinct in the wake of a mistake, but it<\/span> impedes an organization\u2019s ability to learn and reduces patient safety to a reactive role, rather than one that proactively seeks to reduce harm.1<\/sup> What can those charged with investigating incidents do then to ensure that a comprehensive approach to learning is followed?<\/span><\/p>\n

To ensure that learning and improvement occurs from any event, incident investigation must transcend the \u201cfirst story\u201d (where human error is the cause) and seek out the \u201csecond story,\u201d which is a deeper, richer assessment of the event.2<\/sup> 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<\/sup> Although hypothesizing the cause of this event may be helpful in guiding the direction of the investigation, it\u2019s important that investigators keep an open mind<\/span> so they\u2019re not subject to cognitive biases during the process.4<\/sup> Three components to consider during incident review include interviews of involved team members, simulation of the event, and creating viable strategies to avoid recurrence.<\/span><\/p>\n

Focused interviews<\/strong><\/p>\n

Once a cursory outline of an adverse event has been established, investigators need to interview the staff members involved.3<\/sup> 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\u2019 supervisor(s) at the meeting, so that candor is not impeded.5<\/sup> 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<\/span> how to best conduct these interviews can be garnered from the fields of simulation debriefing6<\/sup> and crisis negotiation.7<\/sup> For instance, the interviewer should avoid starting a question with the word \u201cwhy\u201d as it typically triggers a defensive response. Replacing the question \u201cWhy did you\u2026?\u201d with \u201cWhat led you to\u2026?\u201d can diffuse the perception of being accused of wrongdoing.\u00a0\u00a0<\/span><\/p>\n

Simulation<\/strong><\/p>\n

Simulation of an adverse event has been frequently used to augment the investigative process.8<\/sup> 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<\/sup> 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 \u201cMiracle on the Hudson\u201d) 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\u2019 decision to ditch the aircraft.10<\/sup>\u00a0<\/span><\/p>\n

Sustainable strategies<\/strong><\/p>\n

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.\u00a0 One theory of risk management, the hierarchy of intervention effectiveness, suggests that<\/span> strategies focused on systems (i.e. automation & standardization) are superior to improvements focused on people (policies & training).11<\/sup> 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<\/span> 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<\/sup>\u00a0\u00a0\u00a0\u00a0<\/span><\/p>\n

Creating a medical department with a memory is a formidable task and will mean <\/span>approaching adverse events differently than we have typically done before. The attribution of \u201chuman error\u201d 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.\u00a0\u00a0<\/span><\/p>\n

Jonathan Cohen<\/strong> 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\u2019s degree in patient safety leadership and has been an invited speaker on the topic at national professional meetings. Twitter @JonathanCohenMD<\/a><\/em><\/p>\n

Sephalie Patel<\/strong> 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.<\/em><\/p>\n

Competing interests:<\/strong> none declared.<\/p>\n

References:<\/b><\/p>\n

    \n
  1. 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<\/em> 2015; 2:303-310.<\/span><\/li>\n
  2. Woods DD, Dekker S, Cook R, Johannesen L, & Sarter N. (2010). Behind Human Error<\/em>, 2<\/span>nd<\/span> Edition. Burlington, VT: Ashgate.<\/span><\/li>\n
  3. Vincent C, Taylor-Adams S, Chapman EJ, et al. How to investigate and analyse clinical incidents: Clinical Risk Unit and Association of Litigation and Risk Management protocol. BMJ<\/em> 2000; 320: 777-781.<\/span><\/li>\n
  4. Sanchez JA, Lobdell KW, Moffatt-Bruce SD, Fann JI. Investigating the Causes of Adverse Events. Ann Thorac Surg<\/em> 2017; 103:1693-1699.<\/span><\/li>\n
  5. AHRQ. System-Focused Event Investigation and Analysis Guide. Retrieved from <\/span>https:\/\/www.ahrq.gov\/professionals\/quality-patient-safety\/patient-safety-resources\/resources\/candor\/module4-guide.html<\/span><\/a>\u00a0<\/span><\/li>\n
  6. Rudolph JW, Simon R, Dufresne RL, Raemer DB. There\u2019s No Such Thing as \u201cNonjudgmental\u201d Debriefing: A Theory and Method for Debriefing with Good Judgment. Simul Healthc<\/em> 2006; 1:49-55.<\/span><\/li>\n
  7. Voss C & Raz T. (2016). Never Split the Difference: Negotiating As If Your Life Depended On It<\/em>. New York: HarperCollins Publishers.<\/span><\/li>\n
  8. Simms ER, Slakey DP, Garstka ME, Tersigni SA, Korndorffer JR. Can simulation improve the traditional method of root cause analysis: a preliminary investigation. Surgery<\/em> 2012; 152:489-497.\u00a0<\/span><\/li>\n
  9. Slakey DP, Simms ER, Rennie KV, Garstka ME, & Korndorffer JR Jr. (2014). Using simulation to improve root cause analysis of adverse surgical outcomes. Int J Qual Health Care<\/em> 26(2):144-150.<\/span><\/li>\n
  10. 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.\u00a0 Aircraft Accident Report NTSB\/AAR-10 \/03. Washington, DC.<\/span><\/li>\n
  11. Cafazzo JA, St-Cyr O. From Discovery to Design: The Evolution of Human Factors in Healthcare. Healthc Q<\/em> 2012; 15: 24-29.\u00a0<\/span><\/li>\n
  12. Higham H, Baxendale B. To err is human: use of simulation to enhance training and patient safety in anaesthesia. Br J Anaesth<\/em> 2017; 119: 106-114.<\/span><\/li>\n
  13. Flin R, O\u2019Connor P, Crichton M. Safety at the Sharp End: A Guide to Non-technical Skills<\/em>. CRC Press 2008.\u00a0<\/span><\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"

    The attribution of \u201chuman error\u201d must mark the beginning, rather than the end, of the search for contributing factors to an adverse event, say Jonathan Cohen and Sephalie Patel […]<\/p>\n

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