Perhaps, as Terry Fairbanks said yesterday, we should look not to our individual pursuits but the healthcare system that is in place. Individually, we are each committed to the reason we put on the white coat – to cure, heal, and do our best to care for each of our patients. And yet collectively as a system we are failing to provide that very goal. How is it possible that such dedicated individuals are systemically failing – it would appear to be impossible, and the numbers certainly show that its more than just a few bad apples. Perhaps our system needs to be overhauled.
I was struck at the insight that Dr. Fairbanks shared. As a human factor engineer he explained that every other system in the world accounts for the natural errors in humanity. There are fail-safes embedded in most systems to catch the errors before they cause undue harm. Such fail-safes are not present in the culture of healthcare. While every hospital is claiming to be patient-centered, we often fail to see the humanity within ourselves. I am firmly convinced at this point that a systemic culture change is the only solution to our never-ending problem of patient safety. Dr. Fairbanks made it clear that skill-based errors (or better put, automated errors) are the key to controlling our out of control safety issues. In fact, as a first year medical student we learned in our neuroscience course about types of memory: short-term, declarative (semantic and episodic), procedural, priming, associative, and non-associative. The last of these (non-associative learning) is when someone is habitually exposed to the same event over and over again that the event is done by rote. This should sound familiar, as it’s the same as skill-based tasks that require automation or limited cognitive input in order to be achieved.
From my class example, this is when you live over a flight path (which I actually do), and you tune out the sound of the overhead planes because you hear them every few minutes. Every once in a while a plane will fly lower causing a louder that normal event that triggers you to notice them again, and again with habituation it disappears from your thoughts. So it is clear that our mind can become habituated by automated responses that require little cognition, and it is only when there is a difference that your routine is noted. Hence is the case discussed today of the NICU heparin incident – habituation caused major medical errors. I am fascinated by the idea that this system error could have been avoided if there had been a slight difference (a different shaped vial, a different drawer, any change from the expected norm). Dr. Fairbanks would argue that this is how well-meaning, caring professionals make simple mistakes that cost lives – and it is not the individual practitioner, it is the system involved regardless of how mindful we may be. That same error was noted in the book “Why hospitals should fly” when the flaps were not engaged yet 3 people confirmed a 15,15 green (indicating the flaps were extended) – it was the expected result and therefore it was what was seen. These sorts of systemic errors are where the most margin for improvement can occur – because like any job, medicine becomes routine and we become habituated, and our brains are physiologically wired to become habituated.
To say this conference has been insightful would fall short of its true meaning in my eyes as a future medical professional. These past two days have shown me that our profession is far from perfect (even though each of us strives for such), and requires some major safety overhaul before the public catches wind of our missteps. In fact, I’m not sure how much longer we can pull the wool over their eyes before they catch us red-handed, and I’m not exactly sure how we have been fooling them for as long as we have. The numbers are out there, the mistakes make headlines, and yet we are still more trustworthy than a stranger on the street, and we deserve no such pride. As medical professionals, its time to put egos aside and start doing what we swore an oath to do: do no harm.