Human error: models and management

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System approach to Medical Error
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Medical error

• Different Approaches

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Different approaches

• The problem of human error can be viewed in 2
  way
• The person approach
• The system approach
• Each has its model of error causation, and each
  model gives rise to different philosophies of
  error management

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Person approach
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Person approach, basis

• The long-standing and widespread tradition of
  person approach focuses on the unsafe acts
  -errors and procedural violations- of people on
  the front line nurse, physicians, surgeons,
  anesthetists, and pharmacists.

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Person approach, philosophy

• This approach views these unsafe acts as arising
  primarily from aberrant mental processes such as
  forgetfulness, inattention, poor motivation,
  carelessness, negligence, and recklessness.
• People are viewed as free agents capable of
  choosing between safe and unsafe mode of
  behavior.
• If something goes wrong, a person or group must
  be responsible.

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Person approach countermeasures to errors

• The associated countermeasures are directed
  mainly at reducing unwanted variability in human
  behavior.
• Posters that appeal to peoples fear,
  disciplinary measures, threat of litigation,
  retraining, naming, blaming, and shaming.
• Followers of these approaches tend to treat
  errors as moral issues, assuming that bad things
  happen to bad people- what have been called the
  just- world hypothesis

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person approach, why?

• Blaming individuals is emotionally more
  satisfying than targeting institutions.
• Uncoupling of persons unsafe acts from any
  institutional responsibility is in the interests
  of managers
• Person approach is also legally more convenience.

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Person approach shortcomings

• Although some unsafe acts in any sphere are
  egregious, most are not.
• In aviation maintenance about 90 of quality
  lapses were judged blameless.

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Person approach shortcomings

• Effective risk management depends crucially on
  establishing a reporting culture. Without a
  detailed analysis of mishaps, incidents, near
  misses and free lessons, we have no way of
  uncovering recurrent error traps.
• The complete absence of such a reporting culture
  contributed crucially into the Chernobyl
  disaster.
• Trust is a key element of a reporting culture,
  and this in turn, requires the existence of a
  just culture-where the line should be drawn
  between blameless and blameworthy actions.

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• Engineering a just culture is an essential early
  step in creating a safe culture

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Blame and punishment

• Anticipation of blame promotes cover up
• Fear of criticism in close calls and near misses
  precludes rational analysis of possible injury
  precursor mechanisms, and thus the opportunity
  for constructive accident prevention

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System approach
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System approach

• Humans are fallible and errors are to be
  expected, even in the best organizations,
  especially in complex organizations
• Errors are seen as consequences rather than
  causes, having their origins not so much in the
  perversity of human nature as in upstream
  systemic factors.

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System approach

• Humans are fallible and errors are to be
  expected, even in the best organizations,
  especially in complex organizations
• Errors are seen as consequences rather than
  causes, having their origins not so much in the
  perversity of human nature as in upstream
  systemic factors.

Error
Event
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System approachcountermeasures to errors

• Although we can not change the human conditions,
  we can change the conditions under which the
  human work.
• A central idea is that of system defenses.
• All hazardous technologies posses barriers and
  safeguards.
• When an adverse event occurs, the important issue
  is not who blundered, but how and why the
  defenses failed.

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The Swiss cheese model of how defenses, barriers,
and safeguards may be penetrated by an accident
trajectory
Slices of Swiss cheese As defensive layers
Holes as weaknesses In defensive layers
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The Swiss cheese model of system accident

• Defenses, barriers, and safeguards occupy a key
  position in the system approach. High
  technology systems have many defensive layers
• some are engineered
• alarms, physical barriers, automatic shutdowns
• others rely on people
• surgeons, anesthetists, pilots, control room
  operators
• others depend on procedures and administrative
  controls.
• they are mostly effective at this, but there are
  always weaknesses.

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The Swiss cheese model of system accident

• The holes in the defenses arise for 2 reasons
• Active failures
• Latent conditions

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Active failures in Swiss cheese model

• Active failures are the unsafe acts committed by
  people who are in direct contact with the patient
  or system (slips, lapses,mistakes, and procedural
  violations).
• Active failures have a direct and usually
  short-lived effect on the integrity of the
  defenses.

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Latent conditions in Swiss cheese model

• Latent conditions are the inevitable resident
  pathogens within a system.
• They arise from decisions made by designers,
  builders, procedure writers, and top-level
  management.
• They can translate into error-provoking
  conditions within the workplace (time pressure,
  understaffing, inadequate equipment, fatigue, and
  inexperience)
• They can create long-lasting holes and weaknesses
  in the defenses (untrustworthy alarms and
  indicators, unworkable procedures, design and
  construction deficiencies).

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Interaction between active failures and latent
conditions

• Latent conditions may lie dormant within the
  system for many years before they combine with
  active failures and local triggers to create an
  accident opportunity.
• Active failures are often hard to foresee but
  latent conditions can be identified and remedied
  before an adverse event occur.
• This approach leads to proactive rather than
  reactive risk management

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• Active failures are like mosquitoes, they can be
  swatted one by one, but they still keep coming.
  The best remedies are to create more effective
  defenses and to drain the swamps in which they
  breed. The swamps, in this case, are the
  ever-present latent conditions.

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Error management

• Error management has 2 components
• Limiting the incidence of dangerous errors (this
  will never be wholly effective).
• Creating systems that are better able to tolerate
  the occurrence of errors and contain their
  damaging effects.

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Error management

• Followers of the person approach direct most of
  their management resources to trying to make
  individuals less fallible or wayward.
• Followers of the system approach strive for a
  comprehensive management program aimed at several
  targets the person, the team, the task, the
  workplace, and the institution.

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Error management

• James Reason (1997) defines error management at
  the organizational level as having two
  components
• Error reduction consists of measures taken to
  limit the occurrence of errors
• Error containment consists of the measures taken
  to limit adverse consequences.

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Error management

• Error management at the person level is defined
  as actions taken either
• Error avoidance to reduce the probability of
  errors occurring
• Error trapping to deal with errors committed
  either by detecting and correcting them before
  they have operational impact
• Error mitigation to contain and reduce the
  severity of those that become consequential

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High Reliability Organizations

• Systems operating in hazardous conditions that
  have fewer adverse events. (e.g. Nuclear power
  plants, air traffic control centers, nuclear
  aircraft carriers)
• Such a system has intrinsic safety health it is
  able to withstand its operational dangers and
  still achieve its objectives.

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Defining characteristics of high-reliability
organizations

• They were complex, internally dynamic, and
  intermittently, intensely interactive.
• They performed exacting tasks under considerable
  time pressure.
• They had carried out these demanding activities
  with low incident rates and an almost complete
  absence of catastrophic failures over several
  years.

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Variability and Reliability

• Managers of traditional systems attribute human
  unreliability to unwanted variability and strive
  as far as possible to eliminate it.
• In high reliability organizations, it is
  recognized that human variability in the shape of
  compensations and adaptations to changing events
  represents one of the systems most important
  safeguards.

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• Reliability is a dynamic nonevent .
• It is dynamic because safety is preserved by
  timely human adjustments.
• It is a nonevent because successful outcomes
  rarely call attention to themselves.

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Different modes in high reliability organizations

• HROs can reconfigure themselves to suit local
  circumstances.
• In their routine mode, they are controlled in the
  conventional hierarchic manner.
• In high tempo or emergency situations, control
  shifts to experts on the spot
• The organization reverts to the routine control
  mode once the crisis has passed

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High reliability organizations

• The most important distinguishing feature of high
  reliability organizations is their collective
  preoccupation with the possibility of failure.
• They expect to make errors and train their
  workforce to recognize and recover them.
• They continually rehearse familiar scenarios of
  failure and strive hard to imagine novel ones.

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• Instead of isolating failures, HROs try to
  generalize them.
• Instead of making local repairs, they look for
  system reforms.

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Clinical practice as a high reliability
organization

• In the past 15 years a group of scientists based
  in Berkeley, California, and the university of
  Michigan at Ann Arbor have studied safety success
  in HROs and their use in clinical practice

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Relative risk

• Iatrogenic hospital death rate 3 per 1000
  discharges (0.3)
• Commercial airline death rate 1 per 8 million
  passengers (0.0000125)

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Goal set by institution of medicine report

• A 50 reduction in medical errors over 5 years