Clinician Decision Errors In Work

Dr Ares LeungDeputy Medical Director

9 October 2010

Scope Of Coverage

Only errors in bedside/similar work are discussed System causes, typos and transcriptions, wrong prescription, etc

are not covered What are they When are they significant

Reasons behind clinician decision errors: a humanistic discussion

Why errors occur with good doctors

When errors occur: damage control and continuation in role of care provider

Prevention of errors

Support available in UH

Agenda

What is an error?

Causes of errors

How to handle errors?

Support Available in UH

Error (James Reason)

Upright (trip or stumble) Current intention (slip or lapse)

Appropriate route towards goal (mistake) Righteousness (sin)

‘Big’ Error, Simple Overlooking

Classification Of Errors By Outcome

Outcome determines whether deviation is error, neutral or even good innovation

Free lessonsFree lessons

Near misses as learning

ExceedancesExceedances

Overdoing for sake of safety

IncidentsIncidents

Near misses of sufficient severity to warrant reporting &/or internal investigation;

e.g. minor harm done or major harm marginally defended

AccidentsAccidents

Significant adversity arising

Medical setting: the most significant, and present focus

Classification Based On Action

Intrusions

appearance of unintended actions

Intrusions

appearance of unintended actions

Repetitions

(of actions already performed)

Repetitions

(of actions already performed)

Wrong objects

right actions on wrong objects

Wrong objects

right actions on wrong objects

Misordering

right actions in wrong sequence

Misordering

right actions in wrong sequence

Mistiming

right actions, wrong time

Mistiming

right actions, wrong time

Blends

unintended merging of 2 action sequences directed

to different goals

Blends

unintended merging of 2 action sequences directed

to different goals

OMISSIONS

difficult to explain / defend

OMISSIONS

difficult to explain / defend

Error Prevention

= Experience of others

= Non-compliance causes problems

Model Borrowed From Driving

Speeding

Illusions Behind Driving Violations

Illusion of Control Feels powerful and overestimate extent to which one can govern the

outcome of risky situation

Illusion of invulnerability Underestimates the chances that rule breaking will lead to adversity

Illusion of Superiority I am more skilled than others

Thinking that he has no higher tendency to violate than others

Characteristics of Rule Deviants

High opinion of own skills over others

Individuals relatively experienced and not especially error prone

Subjects with history of incidents & accidents

Workers less constrained by opinions positive/negative of others about outcomes

Young men

Therefore DOCTORS

Agenda

What is an error?

Causes of errors

How to handle errors?

Support Available in UH

Reasons For Clinician Error

Lack of checking mechanisms Other staffs: many checkers Nurses: 3 checks, 5 rights Doctors:

• usually one-to-one interaction with client;

• no one else to check;

• Issue of confidentiality

Clinician Image as final and authoritative No remedy

Doctor: Robin Hood With 1 Arrow

Liability Related to Clinician Decision

Natural disease process: Fate, God’s will, ‘mother nature’

Result of Clinician Intervention / conscious non-intervention

Liability (although usually credit)

Orthodox Management

Protection from Orthodox Care

Patient Happy Patient Unhappy

Expected Outcome Success Wrong expectation

Unfavourable Outcome

God’s Will God’s Will

Every care provider is ‘clean’.

Care Not Orthodox

Patient happy Patient Unhappy

Outcome favourable Luck Suboptimal Counseling

Outcome unfavourable

Forgiving Patient Mistake, liability

Determinants To Outcome of Medical Error Adherence to orthodox management or otherwise

General perception from client about trustworthiness Perceived competence and care Issue of unmatched expectation about trust

- Performance falls short

- Expectation driven too high (patient and clinician contributions)

Outcome

Patient Satisfaction and agenda

Damage Control: communication and care when outcomes unfavourable

Departure From Orthodox Care

Knowledge base

Deliberate non-compliance

Usual track: leaving outcome to probability

Procrastination: dragging on

Bias Which Take Us over after Deviations

Go for similarity: take forms that correspond to salient aspects of the problem configuration

Take reference to frequency: take contextually appropriate, high frequency forms

Previously reinforced modes of handling

Limitation in brain capacity (bounded rationality): conscious workspace being limited in capacity, is liable to spillage / preoccupation, & overload

(Laziness) Reluctant rationality: there is strong preference for automatic, parallel processing, even when the conditions demand computationally powerful but effortful serial processing.

Irrationality

Factors Favouring Non-compliance

A. I don’t know!

B. Fatigue

Prevention Human: work arrangement, training Computers for info transferal,

monitoring and alert: no fatigue

Definite factor

Common element

Reduces memory and adherence with orthodox care

Encourages short-cuts

C. Stress

Stress and anxiety Initial improvement in performance Then performance falls as stress increases

Overloading is a potent cause of stress (plus independent effect to by-pass safety measures)

Different people handle stress differently Calm & cool, alert & responsive; versus emotional, troubled, anxious, frustrated,

social defect senses Personality Even in same person: time, situational and preparedness difference Setting: lack of control, new environment, external factors (personal, family &

social, etc)

D. Non-compliance To Safety

Usual Co-workers are reluctance against changes:

Non-compliance to policies and safety measures – e.g., computerization, hand-washing, personal clothing

Personality: 2 – 16% of general population exhibit oppositional defiant disorder

Persistent testing of limits, ignoring rules, exhibiting stubbornness or unwillingness to negotiate or compromise (usually borderline & nonpathological)

American Psychiatric Association 2000

E. Impact from Awareness

High vigilance demand: rapid increase in error rate over time

Multitasking especially demanding

Human brain automatically selects focus point, width and depth in each process while multitasking

Everyday example: talking over phone while driving / other activity: you may not be aware of roads traveled

Demand: error free process!

F. Change in Care Setting

Beginner’s Luck It does not exist There is only beginners’ unluck

Change of status: public to private practice Public system: team support; rapid change to practically solo situation in

private medicine – virtual multitasking

Change to a new hospital: Subtle changes in cooperation, habits, culture, settings Attention to every detail mandatory Help from a buddy, however experienced one is

G. The Selfish Giant

Personal Gain Element Possible personal agenda

Financial / Convenience / Client factor

Masking by

Confidentiality

Autonomy

Discrepancy in knowledge between client and attendant

Occasion inappropriate requests from clients: formation of a syndicate (issue with third party payment)

Lack of clinical audit

Personal Gain Element: Detection

Very high ethical / reputational damage if accusation confirmed

Practitioners unfriendly to colleagues are not at higher risk of deviations

The deviation in intervention reflects the intention (designed by the practitioner), and a tendency exists (therefore use of statistics)

H. Pendulum

Evolution of Unorthodox Carethe Beginning

The pendulum which gains momentum

Usual initial deviation very small and suited both clinician and client

Positive reinforcement about Getting away Apparent advantage to practitioner Apparent advantage to some clients (cost, convenience)

Unorthodox Care Evolution

It worked last time(s) Initial high chance of favourable outcome Medical risk: significance of 10% mortality – high risk and yet

90% get away

Private Practice: no one else knew (rank dependence in public sector)

Protection under ‘autonomy’, ‘confidentiality’

Gradual increase in deviation until significant deviation and high chance of negative outcome

Agenda

What is an error?

Causes of errors

How to handle errors?

Support Available in UH

Why Does Bad Outcome Occur After Good Care

It is misfortunes which differentiate the best doctors from the good ones

Why does God give me bad outcomes when I am careful already?

Because I know how to manage bad outcomes better than others.

Finances come last: Doctors are lucky people who are not bound by money Take care of patients’ wallets as well Never walk away after errors because of negative financial return

When Errors Do OccurInternal Management: Admittance

Admittance to oneself & team Honesty: telling the truth (to ourselves and others)

Integrity: living that truth

Toughest part in whole process: realizing and admitting fault At the core of most problems is a truth one does not want to face

A minute of being honest with oneself is worth more than days, months, or years of self-deception

(adapted from ‘The One Minute Apology’)

Art of Enlisting Team Support

Denial / deferral lead to additional damage, negative effect on integrity, and image in peers

The longer one waits to disclose errors to the team, the more his weakness is perceived as wickedness

Not just use of words (behaviour, organization of presentation, body language about attitude are important)

Change in pattern of management to prevent similar occurrence, as soon as it is feasible.

Preservation of peer image in honesty and Integrity

Highest attainment: openness To colleagues (let others learn from our own mistakes) To clients

(adapted from ‘The One Minute Apology’)

Personal Creditability(Not Affected By Admittance To Errors)

Track record

Self awareness

Respect from peers and clients, trust

Base directives on logic and humane care, not creditability, personal fame, titles, positions, mere records

Ability to admit failure and apologise

Personal Responsibility Versus the System

Very common saying: the system is at fault

Who operates the system

Determinant of proportion of responsibility: personal control to the system

Private medicine: a lot of personal control available

We doctors are respected and irreplaceable because we shoulder responsibility

Use of Continuum in CarePersonal Efforts

Engagement of clients from beginning of care about possibility to alter courses of care

Monitoring of trend far more accurate than spot conclusions

One cannot be wrong when he has not yet committed,

A matter of scale in application (percentage of cases so managed)

- Family care (automatic return with unfavourable outcome)- Specialty Medical care- Hospital/procedural intervention

In a client (influenced by degree of certainty, urgency of intervention; still applicable to every client

Reduction in Chance of Dissatisfaction upon Error

Patient Rapport and Trust reduces probability of complaint upon error occurrence

Rapport and Trust a function of perceived competence and care

Perceived competence grossly reduced at occurrence of error which affects welfare May not be changed if there is error but no damage

Perceived care: a matter of communication

Communication to Reduce Complaint upon Error

Continues after error happens

Frank disclosure and engagement of patient, family & friends in remedy

Frequent and effective attendance

Continuation of professionalism and care

Apology to Client

Limitation by consequences and collective indemnity organization

Not for outcome, but because it was the right thing to do to apologize after wrong doing

Difficult to balance

Enlist the experienced Usual gentle diversion to communication

Prevention of Medical ErrorsPersonal Efforts

Meticulous adherence to orthodox care

Review of each less favourable situation What could have been different? Empathy: in shoes of other party Admission to self that mistakes are possible Find and practice changes

Elimination of ‘leads with least resistance’ towards unorthodox care

System Prevention of Clinician Error

Quality Assurance activity Establish an open system to make unfavourable outcome known to a

peer group Mutual help to prevent deviation towards the unacceptable Frequent and open, continual if possible

System to receive complaints: Customer Services Dept Direct feedback from clients Very painful Useful

System to evaluate clinician activity before incidents occur Survey on satisfaction to doctors

Reasonable Guidelines

Agenda

What is an error?

Causes of errors

How to handle errors?

Support Available in UH

When Something “Bad” Happens

Seek advice

Dr A Leung only 1 phone away

Other experienced seniors The CHM & MD Dr Yu KM, Head of O&G Dr Clara Wu, Head of Emergency Medicine

Many technically superb colleagues available: Senior Consultants, Dept Heads MPS contacts: Richard Butler & JSM