U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M Why We Make Mistakes Jeffrey Young, MD Senior Associate Chief Medical and Quality Officer

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Why We Make Mistakes

Jeffrey Young, MDSenior Associate Chief Medical and Quality Officer

Professor of SurgeryDirector, UVa Trauma Center

University of Virginia Health System


Understanding Clinical Care

• First step in understanding error

• How do we carry out diagnosis and treatment?

• Where are the opportunities for safety?


Effective Care Taxonomy


Cognitive skill

• Knowing how to accurately assess the state of a patient– What data and actions are necessary to get an accurate

assessment• Knowing the significance of the data reflecting the

patient’s current state• Matching the patient’s state to the correct schema• Mentally testing and activating an acceptable action

plan• Follow-up


Background

• Medical education– Even problem based curriculums are not truly

tactically oriented• Issue – data- analysis- action- reassessment

– Differential diagnosis• Look at data and create diagnosis list based on

characteristics of conditions and their relation to the data you currently have available

• Then look at list and decrease number of diagnoses until you are left with one


Tactical Assessment

• We are not trained to rapidly assess a situation, look at the key elements, discard less important inputs, create an action plan, implement it , and see if it worked

• Military does this very well, as do other high risk jobs (aviation, etc.)


Current Process

• Do a thorough history and physical examination– Chief complaint

– HPI

– ROS

– Medications

– Allergies

– Physical Exam

– Assessment

– Plan


Assessment/Plan

• Signs and symptoms lead to potential diagnoses– Diagnoses lead to investigation– Through investigation diagnoses are supported or

discarded– You are left with your most likely diagnosis– Then you initiate a treatment plan


Paradigms

• Definitive treatment delayed until all possibilities are entertained and evaluated

• There is concern that aggressive early intervention can lead to overtreatment, incorrect therapies, or complications of medications and procedures


Bottom Line

• Some patients have time for thoughtful evaluation

• Some do not

• First cause of error: not making the above characterization of the patient correctly


Technical Skill

• Knowing the indications for a test or procedure• Knowing how to safely carry out the action, and all

possible adverse events related to that procedure• Insuring backup and help if needed• Monitoring the patient during the procedure• Correctly interpreting the results of the procedure• Following up to insure absence of adverse event


Teamwork

• Can not carry out technical act, nor action plan without other competent individuals or processes

• Need to know how to engage the care team– Advice members of goal, path to goal, alternative paths if

they arise,– Framework for communication– Checklists and Time outs

• CRM principles during action plan• Follow-up


Example

• Intern is on call and at 1AM nurse calls:– “ Mr. Smith who had a stent placed for a AAA

today is having some belly pain and his temp spiked to 38.7C”


Opportunity of Error

• Intern– “Well…how bad does his belly hurt?”– “He had his procedure today, I’m sure he just has

some atelectasis, make sure he uses his incentive spirometer”

– “Thanks for the call”


Error

• Have we given that intern the tools to ask the right questions and do the right things?

• Have we prepared him to fail in this case or succeed?

• Would a better understanding of how people make errors improve his chances of success?

• Can we learn from other high risk industries?


Experience and Error

• Novices– Novices (or people inexperienced in that domain)

do not yet have the experience and knowledge to make correct decisions

• They don’t know what can go wrong• Don’t know the cues• Don’t even know what data to look for

– Thus they must depend on an overall philosophy or mindset toward events to guide their decisions

– If that mindset is dangerous, bad care will result


Experience and Error

• Experts– When you are an expert, you’ve gained the

experience and knowledge to properly make decisions

– You know what data is essential and what is extraneous

– You can look for cues that put you down the correct path

– Can we teach this? Or do you have to live it?


Types of Errors


Types of Errors

• Slips– Failures to properly adjust tasks that require little

conscious attention to the characteristics of a new situation

• Without thinking, ordering an adult dose of a med for a child

– Correction• Make it difficult to do the wrong thing• Error requires more steps and positive affirmation

– “Do you really really want to format C:?”


Types of Error

• Lapses– Failures of memory that cause tasks not to be done– Common in task overload or distraction– How to avoid?

• Train in high intensity situations• Clear pre-arranged plans that require little creative

thought and may not be perfect, but are SAFE• Reminders• Same corrective actions as for slips


Errors

• Mistakes– The selection of incorrect actions by

misclassifying a situation or failing to take into account all relevant factors in a decision

• Evaluating for nausea and vomiting but not taking into account new onset DM as a cause

• Attributing cold symptoms to the URI and not realizing degradation in cardiac function is the cause

– Perfect execution of incorrect plans distinguishes this from lapses and slips


Error Generators

• Assumptions– It must be OK or someone would say something

• Generalizations– Didn’t happen last time, why should it happen this time?

(translation; I got away with it last time….)

– Successful folly is folly nonetheless (Jim Hurst, MD)

• Pushing a bad system to the limits– Without working on making the system better


Error Generators

• Laziness (not that common)

• And number 1(‘s)!– Too little FEAR that things can go wrong

• “Fear does the work of reason” – Winston Churchill

• quickly and with very little warning.

• Making CERTAIN that the conditions are stable or improving before moving on

– Too little FEAR that you don’t know everything


Common Causes of Clinical Error

• Incorrect triage of problem– Problem more serious than most people realize

• Insufficient fear of being wrong• Practitioner has not seen enough clinical situations to

know all possibilities– Buggy knowledge – they fill in their knowledge gaps with

generalizations

• No follow-up– Almost all major disasters can be averted by simply going

back and reassessing the patient


Error Recovery

• Lack of cognitive understanding of condition or state by all practitioners (Most common cause of adverse events I see)– Team does not have enough experience or know

enough to realize what is going on with patient• Patient in ectopic units• Specialists not available• Patient at low capability facility (don’t understand who

is at risk)


Error Prevention

• Very complex issue

• Systems, education, decision making, communication

• New knowledge, new techniques and procedures

• Information systems


Fear of Being Wrong

0

10

20

30

40

50

60

70

Pessimistic(percent ofsubjects)

Algorithmic

< 4 Weeks ICU

>4 Weeks ICU


What Can We Learn From Studies of How Experts think?

• Schema (what is the mindset you are using with this patient?)– You actually decide what “kind” of patient you

have very rapidly (almost instantly), but you may not realize it

• Visualize care plan– In mind, can I see this patient going home the way

they look now?– Does the patient look like the typical patient who

is admitted for this type of problem?


Very few major disasters result from a single error

“Tactical catastrophes are rarely the outcome of a single poor decision. Small compromises

incrementally close off options until a commander is forced into actions he would never choose freely” –

Nate Fick


Situations Where Error May be Unrecoverable

Tenerife: March 27, 1977Worst Aircraft Accident in History

Factors:Inadequate technical skills of ATCSuspect plan (?)Experienced pilot (top airline pilot at KLM)Fog

No ground control radarCRMStepped on transmissionsNo warning system for active runway


Diagram


Errors

• Cognitive– Decision to take off– Decision to place both planes on runway– Decision to refuel

• Technical– No ground radar– Communication equipment inadequate

• Teamwork– Cockpit and control tower teams



Tenerife

• This accident (more than any other) changed the culture of air safety– To be honest, we have not yet had such an incident in

medicine (IOM report?)

• When people realized even the most experienced pilot could make egregious error, conclusion reached that human performance must be enhanced with safety measures

• Sometimes we just do real stupid things


Experience and Deliberate Practice

– “Good judgment comes from experience, and experience comes from bad judgment “

– “Luck is not method, and neither is hope. Hard work is.”

– Can we produce safe doctors with decreasing clinical experience?


Decreasing Errors


Role of “Philosophy” of your team and facility

• What is your “Philosophy of care”?– Get as many patients seen as possible?– Increase patient volumes by 10%?– Insure every patient gets recommended care?– Think of the worst thing that could be going on

with the patient and rule it out?– Save money?– Avoid unnecessary radiation and testing?


Philosophy

• Some philosophies may be at odds– Increase volume vs. provide safe care– If care is barely being safely provided at present volume,

how can you expect higher volume will allow safe care without system changes?

• Trauma service functions with safeguards and double checks for a ICU census of 8—10 and a floor census of 10-12– What happens when ICU census increases to 20 and floor

census increases to 25??– Do you have a contingency plan that goes into effect (like

the military, police and fire do)


“Try Harder”

• Just telling people to “try harder” or “make less mistakes” or “take better care of the patients” rarely is an effective strategy

• Most people are trying pretty hard and their output is more dependant on the system they are working in, not their effort


Decision Making

• Can teaching medical practitioners traditional clinical reasoning be detrimental?

• Naturalistic Decision Making– Gary Klein

– Under conditions of uncertainly, time pressure, and high risk (medicine), experts do not use analytical methods.

– They use fast and “sufficient” strategies• In other words they don’t search for the “best” answer, just the first

“acceptable” answer


How do experts make decisions?

• Look at patient and data• Fit that data into a schema they have seen before• Choose a plan based on their previous experience

– This is why inexperience is devastating• War game the plan and its execution in their head

(think about it, you really do this)• If plan simulates OK, proceed

– If it doesn’t step back and form another option• Repeat as necessary


Centrality of Diagnosis

• Diagnosis has been considered medicine’s central task, but is this best?

• Having a solid diagnosis can make treatment easier, but the lack of a diagnosis does not relieve the necessity to act

• Thus the central task of medicine may be management, not diagnosis

• We should not say, “what is the diagnosis?” but “what should we do now?” (Beth Crandall)


Approach

• Rapid assessment of patients initial presenting data (clinical and digital)

• Rapid intervention of life threatening signs and symptoms– Nothing life threatening

• Narrow to known condition– Mentally simulate treatment and evaluation

» Proceed with plan

» Follow results


Situational Tactics

• We don’t teach this well– How to rapidly evaluate

• Find most important data points

• Assess in relation to other inputs

– Assign priority to actions

– Initiate actions

– Reassess and revise

• You must practice this by running through scenarios over and over again, or seeing patients with similar problems over and over again


Common Emergency Problems

• Mental status change• Injury• Septic conditions• Cardiovascular problems• Respiratory problems• When we look at avoidable death, almost

every case fits in one of these categories


Common Threads in Safely Treating All These Problems

• ABC’s and Call Help• Protect from further injury or deterioration• Rapid exam and assessment of current state and

contributing factors• Form plan

– Mental war gaming

• Initiate– May be harder than it sounds

• Follow-up


Performance by Sessions

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

Initial Evaluation Secondary Evaluation Diagnosis Follow-up Total

Per

cen

t C

om

ple

ted

No Sessions

1-2 Sessions

>2 Sessions

Expert


Errors in Trauma and Surgical Care


Busy Nights (or Busy Units/Services)

• Tests and double checks fall through the cracks– 80 hour does not help this

• Triage attention to severely ill– Leaving less sick to fend for themselves

• Corrective action– Practice

– Have defined algorithms that you stick to• Don’t allow people to improvise just because they are busy

– Its actually the worst time for them to improvise!


Acidosis

• Can be insidious• Need to screen out occult hypoperfusion and you

need to jump on persistently acidotic patients quickly– In elderly, persistent acidosis = non-survivor

– In severe head injury, persistent acidosis = skilled nursing facility

• “The labs must be wrong, ignore them”• Sometimes people don’t want to face the fact the

patients is heading in the wrong direction


Inconsistent Neurosurgical Care

• A major problem• There are few aspects of care everyone agrees with

(despite AANS guidelines)• Often the most junior attending (or resident) is

saddled with trauma • Little synergy between Trauma and Neurosurgical

services (often at odds)• Can we correct?

– Try to get areas of agreement and slowly increase their scope

– Do the same thing every time


Elderly Trauma

• Elderly patients with minimal mechanisms who do not communicate well– Triage problem– Treatment problem

• High risk of respiratory failure• Difficult to get pain free• Interaction with current meds• Underlying disease

• Intervention – focus on the elderly– Especially those with head injuries


Conclusions

• To avoid error you should:– Expect problems– Think the patient is sicker than they look– Define evaluation and treatment algorithms

• And make sure your people understand the reasons behind your algorithms

– If they think its dumb, they wont follow it.

– “Thinking hurts the team”• In many many situations, this is true• Inexperienced people improvising often hurts the patient far more

than it helps

– Practice, Practice, Practice


Some Solutions That Wont Work

• Don’t develop a “wizard” system– Where the patient are only treated correctly when

the “wizard” is around.

• If your system doesn’t work with the most inexperienced, dimmest person at the bedside, then you don’t have a system


Conclusions

• We need to learn how to handle urgent and emergent situations from vocations that deal with this all the time– Cockpit communication and checklists– Rapid military response

• Planning and adaptation under intense pressure• Doing some things every single time, no matter what

– Fire ground• Cross training of personnel• Backup• Chain of command• Bringing in more experienced people


Systems

• Can not always depend on people to make the right decision

• Need to have systems that can rapidly recognize error and intervene

• Need to expect that things will go wrong (Hope is not a method)

• Need to explain why we have safety processes– If people don’t understand them, then their mind

doesn’t engage


Documents

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M Why We Make Mistakes Jeffrey Young, MD Senior Associate Chief Medical and Quality Officer