Ep 7 - "A Life in Error" - Remembering Professor James Reason

Show notes

• Errors occur when a planned sequence of events fails to achieve its goal without an element of chance.
• Slips and lapses are absentmindedness.
• Trips and fumbles are maladroitness.
• Mistakes involve higher order cognition
• Main classification of errors:
  • Skill-based slips
  • Rule-based mistakes
  • Knowledge-based mistakes
• Examples of skill-based slips: putting cat food in the teapot, getting into the bath with your socks on, trying to open a door with the wrong key.
• Examples of rule-based mistakes: proceeding when it’s not your turn at the intersection (most driving errors are rule-based.
• Examples of knowledge-based mistakes: devising an alternate route when there is a road-block, devising a differential-diagnosis and arriving at a working diagnosis.
• In order to prevent, trap, and mitigate errors, we need a common language to discuss errors and how to manage them.
• Violations are intentional deviations from norms and rules.
  • Corner-cutting or routine violations committed to avoid unnecessary effort or to circumvent inappropriate procedures (the written vs unwritten rules);
  • Thrill-seeking or optimizing violations (e.g. speeding);
  • Necessary violations that occur because the people making the rules are not the ones performing the actual work; and
  • Exceptional violations: one-off events that occur under exceptional circumstances.
• The Swiss Cheese Model of defences in depth
  • Defences protect against hazards reaching losses, like barriers.
  • These barriers have holes in them, like swiss cheese
  • The holes are latent conditions and active failures
  • Latent conditions exist for years and are due to system factors (understaffing, policies etc)
  • Active failures are errors created by people at the front-end (doctors, nurses, pilots, technicians etc) that are closely connected in time to bad outcomes.
• The current medical model is not error tolerant. It expects practitioners to be perfect. If a pharmacist, nurse, physician etc makes a mistake, the safety margins are so razor-thin that it can easily result in a bad outcome for a patient.
• Conversely, the response in most medical safety protocols is to warn practitioners of the dangerous conditions and then blame them when the bad outcome occurs, because this time they knew about the dangers. We should instead insist on changing the working environment, which produces the errors.
• Medicine being one of the oldest professions in the world and certainly one of the most complex, contributes to the difficulty in changing its culture.
• In changing the culture of medicine to improve the overall system, we also need to consider how the training of healthcare professionals entrenches the stigma of reporting errors.
• There is no true tension between training excellent physicians and reporting systemic deficiencies, because “stress testing” of physicians can happen in simulations and true-emergencies, while we also work to improve day to day conditions for everyone.
• We are moving towards a model of care where we speak of Centres of Excellence, rather than “who is the orthopaedic surgeon?” Medicine is team-based and even, or perhaps especially, community hospitals whose teams are well-known to each other can deliver excellent and safe care.
• R v Omstead, [1999] OJ No. 570
  • 1999 in Leamington, Ontario Nurse Omstead was charged with manslaughter (criminal negligence causing death) after she gave potassium chloride thinking it was furosemide because they were lookalike drugs stored close together.
  • The judge acquitted Omstead because the Crown failed to prove beyond a reasonable doubt that her actions were a marked departure from a reasonable nurse in her situation. The judge noted that latent conditions such as the drugs looking alike and being placed together were significant factors in the error.
  • The judge also noted that the error had been reported by Omstead herself and a conviction could have a chilling effect on future reporting of errors.
  • Criminal trials are held to determine criminal blameworthiness and judges in such cases cannot make recommendations to hospitals or policymakers.
• Investigating errors as being produced by the working conditions and being related to systemic deficiencies does not mean that individuals cannot be held accountable for gross negligence (e.g. intoxication). It does mean that if, for example, training deficiencies are found, the training system can be corrected and everyone who was similarly situated can benefit.

Safety intervention worth mentioning: leadership walkthroughs

• Dr. John Dornan, New Brunswick’s Health Minister, spends 24 hours in Moncton Hospital’s ED
• Dr. Warren Thirsk challenges Alberta Premiere Danielle Smith to come on shift

Other resources

1. Martin Bromiley: A patient’s perspective (March 16, 2018 - YouTube 23 min)
2. A Life In Error: From Little Slips to Big Disasters by James Reason

Random recommendations

1. Adam: Politics Without Politicians by Helen Landemore
2. Amir: The Black Swan by Nassim Taleb

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