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Nature of Human Error – Implications to Surgical Practice. Alfred Cuschieri Scuola Superiore S’Anna di Studi Universitari Pisa, Italy. Human error – the flip side of the behaviour coin. Study of human error – historical note.

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Nature of human error implications to surgical practice l.jpg

Nature of Human Error – Implications to Surgical Practice

Alfred Cuschieri

Scuola Superiore S’Anna di Studi Universitari

Pisa, Italy



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Study of human error – historical note

  • 1980 Columbia falls conference – John W Senders and Ann Crichton Harris

  • 1983 Bellagio conference ‘Nature and Source of Human Error’ - Senders and Moray NATO sponsored, Rockefeller foundation provided conference venue in Villa Serbelloni

  • Ergonomic psychology/ human factors/ cognitive engineering – Rasmussen, Reason, Anderson, Kirwin, Swain etc.

  • High risk industries – HRA and ALARP region

  • 2003 First conference of surgical errors (COSE) Washington USA


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ERR0R

PROBABILITY

Behaviourist Pyschology

Diagram of Human Actualization – Maslo Abraham


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Anderson’s Theory of Cognitive Architecture

  • Memory systemsWorkingDeclarativeProduction

  • ProcessesEncodingPerformance StorageRetrievalExecution

  • Knowledge representation typesTemporal stringsSpatial imagesAbstract propositions (encode meaning)


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COCOM Contextual Control Model

  • Scrambled Control: Choice of the next action is unpredictable or random. The operator does not have a useful internal model of the world in which he operates

  • Opportunistic Control: corresponds to actions based on the current context as opposed to more fundamental constructs

  • Tactical Control: when operator performance is based on planning. Behavior that is consistent with the rule-based levels of control identified by Rassmussen.

  • Strategic Control: operator has a sufficiently accurate model of the process and the environment to support planning and prediction of high level goals that can be managed across a system of interruption.

  • (Hollnagel, 1997)


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The Internal Processing Classification

  • Input error: the input data are incorrectly perceived (an incorrect intention is formed) hence the wrong action is performed.

  • Intention error: the input data are correctly perceived but an incorrect intention is formed, and the wrong action is performed.

  • Execution error: the input data are correctly perceived, the correct intention is formed, and the wrong action is performed; that is, an action not what was intended

  • James Reason


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Error Modes (Embrey)

  • Mode is the particular appearance of an error when this results in an action

  • Error modes:Omission - leaving out of an appropriate step in a processInsertion - adding of an inappropriate step to a process Repetition - inappropriate adding of a step normally appropriate to a processSubstitution - an inappropriate object, action, place or time instead of the appropriate object, action, place or time


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The human perspective – blame, responsibility for error

  • Blame implies a theory that errors can be perceived by the actor before they are executed, and voluntarily controlled to prevent their execution.

  • Responsibility implies a theory that consequences arise because of flaws in behaviour.

  • Errors, to the extent that we have data, are random; the moment when an error will occur cannot be predicted. There is no "aura" which signals to an actor that an error is about to occur.

  • From the point of view of the actor, the error is unpremeditated - "Operation of uncontrollable natural forces" (Oxford Dictionary)


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‘The actor is the victim of the error; the patient is the victim of the expression of the error in a medical setting which permits the error to be completed and produce an injury’


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Human Errors in Medical Setting victim of the expression of the error in a medical setting which permits the error to be completed and produce an injury’

  • There are no medical errors

  • There are many errors which occur in a medical setting

  • Although we can predict error probabilities, we cannot predict when an error will occur

  • Errors that are not prevented from running their course lead to accidents…but how?


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‘The real problem isn’t how to stop bad doctors from harming, even killing their patients. It’s how to prevent good doctors from doing so.’

A. Gawande: When doctors make mistakes. The New Yorker, 1st February 1999; 40-55.


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How Dangerous is Health Care harming, even killing their patients. It’s how to prevent good doctors from doing so.’

  • Less than 1 death per 100,000 encountersNuclear powerEuropean railwaysScheduled airlines

  • One death in < 100,000 but > 1000 encountersDrivingChemical manufacturing

  • More than 1 death per 1000 encountersBunjee jumpingMountain climbingHealth careJ Smith BMJ


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Factors Modulating Effect of Errors in Hospital Practice harming, even killing their patients. It’s how to prevent good doctors from doing so.’

  • Prevailing external circumstances

  • Interventional activity

  • Efficiency of abortive active intervention

  • Communication defects

  • Poor team work/ skills

  • Surgical approach

  • Complexity of the intervention


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Distal (Coalface) Errors in Surgical Practice harming, even killing their patients. It’s how to prevent good doctors from doing so.’

  • Diagnostic and management errors

  • Resuscitation errors

  • Situation awareness errors

  • Identification/ misappropriation errors

  • Team work errors

  • Prophylaxis errors

  • Prescription/ parenteral administration errors

  • Technical and operative errors


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Surgical Settings harming, even killing their patients. It’s how to prevent good doctors from doing so.’

Setting Risk

Operating room Highest

Intensive care High

Ward Moderate

Ambulatory care ?

Oupatients/ consulting ? Presumed low

Nature of errors likely to differ in these settings – importance of ‘intensivity’ factor


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Error Averse Surgical Care harming, even killing their patients. It’s how to prevent good doctors from doing so.’

  • Neither system nor individual based – but holistic approach or paradigm

  • Interrelated components:Risk avoidanceCoherenceSound infrastructureCultureQuality assuranceElimination of poor performance


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Risk Avoidance harming, even killing their patients. It’s how to prevent good doctors from doing so.’

Well trained staff

Clear Procedures

Safe Environment


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Coherence harming, even killing their patients. It’s how to prevent good doctors from doing so.’

Goals of individual, team and organisation aligned

Excellent communication systems


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Infrastructure harming, even killing their patients. It’s how to prevent good doctors from doing so.’

Access to evidence

Time for planning

Training/ development strategies

Information technology supports practice


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Culture harming, even killing their patients. It’s how to prevent good doctors from doing so.’

Open and participative

Good leadership

Education/ research valued

Patient partnership

Ethos of teamwork


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Quality Assurance harming, even killing their patients. It’s how to prevent good doctors from doing so.’

Best practice spread

Evidence based clinical policies

Anonymous incident reporting systems

Improvement processes integrated


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Poor Performance harming, even killing their patients. It’s how to prevent good doctors from doing so.’

Early recognition

Decisive intervention

Effective self regulation!

Feedback on performance

Re-validation


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Confusing Terminology harming, even killing their patients. It’s how to prevent good doctors from doing so.’

  • Competency:Cognitive skills and knowledge to practice a profession

  • ProficiencyAbility to execute a task at a consistently optimum level and outcome

  • Learningacquisition of new knowledge


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Controlled Conscious Processing harming, even killing their patients. It’s how to prevent good doctors from doing so.’Requires attention control

Error probability highSlow deliberate executionSubject to fatigue

Automatic Unconscious ProcessingEffortlessIntuitive and fast

Reduced error probabilityNot mentally exhausting

Surgical Proficiency - Control Modes


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Training/ Proficiency Zones harming, even killing their patients. It’s how to prevent good doctors from doing so.’

P

E

R

F

O

R

M

A

N

C

E

Proficiency zone

Training zone

Number of cases performed


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Proficiency-gain Curve Documented by HRA harming, even killing their patients. It’s how to prevent good doctors from doing so.’


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Proficiency Maintenance harming, even killing their patients. It’s how to prevent good doctors from doing so.’

P

E

R

F

O

R

M

A

N

C

E

Proficiency zone

Years of independent practice


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Surgical Competency and Proficiency harming, even killing their patients. It’s how to prevent good doctors from doing so.’

  • Long-term process

  • Selection of surgical trainees

  • Training and assessment of of trainees

  • Anonymous incident reporting systems in surgical practice

  • Assessment of established surgeons - revalidation/ re-certification


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Arthur L Bloomfield 1888-1962 harming, even killing their patients. It’s how to prevent good doctors from doing so.’

There are some patients whom we cannot help…..

There are none whom we cannot harm


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When Good Doctors Go Bad harming, even killing their patients. It’s how to prevent good doctors from doing so.’

Lucian L. Leape, MD

American Surgical Association

Boston

August 21, 2006



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ACS Code of Professional Conduct and safe is ethically indefensible.

  • Maintain competence throughout our surgical careers

  • Respect the knowledge, dignity, and perspective of other healthcare professionals

  • Participate in self regulation by setting, maintaining, and enforcing practice standards


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Types of Performance Problems and safe is ethically indefensible.

1. The Psychopathic physician

2. The impaired physician

Substance abuse - alcohol / drugs

Mental illness

Physical illness

3. Declining Competency

4. Behavioral Problems

Disruptive physician

- Refuses to follow rules

- Abusive behavior

Abusive with patients


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Types of Performance Problems and safe is ethically indefensible.

1. The Psychopathic Physician ? 0.1%

2. The impaired physician

Substance abuse - alcohol / drugs 15%

Mental illness 15%

Physical illness 10%

3. Declining Competency


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Recertification Exam Failure Rates and safe is ethically indefensible.(2004)

Board No. % Failed

Am. Bd. Surgery

General surgery 800 4%

Subspecialties 233 9%

Am. Bd. Pediatrics

General pediatrics 3400 1%

Subspecialties 2200 4%

Am. Bd. Internal Med

Internal Medicine 3042 14%

Specialties 3054 10%

Am. Bd. Family Med 6606 11%


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Types of Performance Problems and safe is ethically indefensible.1. The Psychopathic Physician ? 0.1%2. The impaired physicianSubstance abuse - alcohol / drugs 15% Mental illness 15% Physical illness 10%3. Declining Competency 5-10%

4. Behavioral Problems

Disruptive physician


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What do surveys reveal about disruptive behavior? and safe is ethically indefensible.

NURSES:

  • Nurses witnessing or receiving it 95%

  • Verbal abuse every 2-3 months 64%

  • Believe it is a cause of nurses leaving 37%

  • Percent of doctors exhibiting it 5.7%

    HOSP EXECS: 1-5%


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Types of Performance Problems and safe is ethically indefensible.1. The Psychopathic Physician ? 0.1%2. The impaired physicianSubstance abuse - alcohol / drugs 15% Mental illness 15% Physical illness 10%3. Declining Competency 5-10%

4. Behavioral Problems

Disruptive physician ? 5%

Refuses to follow rules

Abusive behavior

Abusive with patients ? 5%


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All causes considered, 30-40% of all physicians will have a problem at some time in their career that will impair their ability to practice medicine safely.

For a hospital staff of 100, this means that at any one time 1 or 2 physicians need help.


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Why are doctors reluctant to act? problem at some time in their career that will impair their ability to practice medicine safely.

  • Distasteful to judge peers

  • Emotionally difficult – “family”

  • “Glass house” syndrome

  • Fear of retribution

  • No good mechanism


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We have a “Non-System” problem at some time in their career that will impair their ability to practice medicine safely.

  • Implicit

  • Personal

  • Punitive

    It’s “all or nothing”


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We define performance problems as disciplinary problems problem at some time in their career that will impair their ability to practice medicine safely.

  • “Hung up” on punishing

    - Want to “weed them out”

  • Safety objective: prevention


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What would we like to do? problem at some time in their career that will impair their ability to practice medicine safely.

1. Identify doctors with problems early

2. Do something about it

3. Do it in a timely fashion

We need a system


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What are the essential characteristics of an effective professional accountability system?

  • Objective - based on data, not opinion

  • Fair - applies to everyone

  • Responsive – prompt and effective treatment

    GOAL: to enable the physician to continue to practice medicine


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What would an effective professional accountability system look like?

  • Adopt performance standards

  • Adherence is a condition of appointment to staff

  • Adherence is monitored (everyone)

  • Feedback of results and action as needed

  • Broad repertoire of methods for remediation


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  • Sub par performance can be objectively defined look like?

  • Routine monitoring of all members of the medical staff is necessary to detect problems fairly and early

  • The response to deficiencies should be prompt, constructive, and sustained


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What is needed? look like?

  • Standards

  • Measures

  • Assessment and remediation programs


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ACGME / ABMS Competency Standards look like?

  • Compassionate, appropriate, and effective patient care

  • Medical knowledge and its application to patient care

  • Practice-based learning and improvement

  • Interpersonal and communication skills

  • Professionalism and ethical behavior

  • Systems-based practice


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Example of a Behavioral Standard look like?

“Treat Co-workers with Respect”

  • Hostile behavior is forbidden (raised voice, insults, public reprimands)

  • No demeaning behavior or humiliation of residents and nurses

  • No derogatory comments about colleagues – oral or written

  • Work in meaningful teams

  • Accept challenges to authority


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What measures are available? look like?

  • ABMS competency measures are being developed

    • ABIM competency testing now

  • Gerald Hickson’s analysis of patient complaints

  • PAR “360” multitrait evaluations


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    What about: look like?

    • Annual physical exams

    • Drug testing

    • Cognitive testing


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    What is needed? look like?

    • Standards

    • Measures

    • Assessment and remediation programs


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    How will we develop programs for assessment and remediation? look like?

    Need a collaborative effort

    ABMS

    FSMB

    JCAHO


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    Are we willing to support recovering doctors? look like?

    • Who pays for assessment and remediation?

    • How is his/her income maintained?

    • Are we willing to make refresher positions available in all of our residency programs?

    • Are we willing to mentor and supervise retrained doctors?

    • Will we let them care for our patients?


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