Wednesday, 28 January 2015

Sisyphus and the recurrence of errors

In their book "Managing Maintenance Error: A practical guide" Reason and Hobbs inform us that most errors are predictable:
"...more than half of the human factors incidents in maintenance are recognised as having occurred before, often many times" (p.98)
In healthcare, a similar pattern emerges. For example, a nasogastric tube is wrongly placed into a patient's lungs and the liquid feed is started. In England and Wales, from 2005-2011 twenty-one people died as result of this error. The commonest drug error in obstetric anaesthesia is mistaking thiopentone for an antibiotic and vice-versa. In the UK, there was at least one incident in 2010, two in 2011,  and one in 2012.

These are examples of error traps. In the seascape of human performance, error traps act as whirlpools, seizing the inexperienced, the tired and the distracted. James Reason tells us that the defence against error traps is organisational. In anaesthesia, the Safe Anaesthesia Liaison Group (SALG) publishes patient safety updates which detail adverse incidents and provide suggestions for avoidance and mitigation. The National Patient Safety Agency (NPSA) performed a similar role for the rest of the healthcare system, but it was disbanded in June 2012, its activity subsumed within NHS England. Many individual departments have morbidity and mortality (M&M) meetings where adverse events are discussed and defences created or adjusted. In addition, individuals will create their own personal defences, such as always having the antibiotic in a 30-ml syringe, triply-labelled.

There are problems with all of these solutions. The patient safety updates are not mandatory reading, there is no assessment of the individual or the department or the hospital to ensure that lessons have been learnt. Attendance at M&M meetings can be variable and sharing of the discussions and conclusions may be sporadic. Individual defences may be breached due to performance degradation or by another healthcare worker who is not aware of them.


Sisyphus (by Titian)
Sisyphus, a deceitful king in ancient Greece, attracted the wrath of Zeus. His punishment: for all eternity he would be forced to roll a boulder up a steep hill, only for it to return to the bottom. In a similar fashion we are doomed to repeat maybe not our mistakes (because we create personal defences) but the mistakes of others. It is extremely likely that the error we were involved with today was made by someone else somewhere else last week or last month.


A number of solutions are called for. Nationally, a system for reporting errors, such as the National Reporting and Learning System (NRLS). These error reports need to be analysed by clinicians and human factors experts to reveal error traps. Also nationally, a mandatory requirement for healthcare personnel to inform themselves of adverse events which are occurring in their field. On a local level, a robust reporting system which feeds into the national system as well as a safety culture, including M&M meetings, which encourages and rewards the reporting of adverse events and near misses. Also on a local level, defined responsibility and accountability for maintaining and modifying system defences.

The role of simulation

Simulation has a number of roles to play. First, systems testing using simulated events, such as a major haemorrhage or a fire, if performed correctly, can reveal weaknesses in the defences. Second, the errors that participants make in the simulation centre are likely to occur in the workplace. For example, in the past few years we have had 2 incidents where, in a crisis, a participant has switched off the anaesthetic machine when they meant to switch on the suction. As can be seen from the image, this is an understandable error. The same error occurred in the actual operating theatre. (It is likely that the same error has occurred a number of times across the UK, as the manufacturer has now designed a clear plastic lid for the anaesthetic machine switch, thus creating a physical barrier.) Do we, as simulation centres, have a duty to flag up common errors to the safety agencies? The third role for simulation is to raise awareness of performance limitations and error traps. Although relying on the person "at the sharp end" to defend against all errors is wrong, it is often that person who acts as the final defence when the system breaks down. Making everybody involved more aware of error traps can therefore only be a good thing.

Thursday, 15 January 2015

Person-centred care: "What matters most to you today?" by Al May

What's this all about?

I read about an interesting concept via twitter the other day.  My understanding was that a hospital ward somewhere was displaying the message "What matters most to me today:" on whiteboards next to patients. The patients would be asked the question and the answer would be displayed for all to see.

It immediately struck me as a simple but potentially powerful way of putting the patient at the forefront of people’s minds.  As an anaesthetist, I don’t have a ward but I do see a lot of patients pre- and post-operatively.  What would happen if I put this question into my pre-operative conversations with patients?  Before I did it, I tried to consider the potential effects.

What were the possible effects of doing this?
On the positive side it might:
  • Unearth some useful information
    • Although I always ask if the patient has any questions, closing with this particular phrase is a slightly more structured way of asking and also a second chance for the patient.

    • Prioritise what matters
      • For example, if a patient answers that the most important thing is not feeling sick, I can then consider and explore with the patient whether a regional technique with opiate sparing would be feasible even when this wasn’t my initial plan based on risk-benefit.  Asking "What matters most to you?" could potentially add another piece of information into the risk-benefit discussion.

    • Let the patient know that you're doing your best
      • I am always trying to do my best for the patient.  However, following the ethos of Fred Lee, author of IfDisney Ran Your Hospital (previously a book of the month) making these aspects visible and letting the patient know can improve the overall experience.

    On the negative side it might:
    • Be misinterpreted
      • The patient could interpret the question as restrictive in that they can only have one thing.  This is however probably dependant on the way the question is phrased and the specific situation.  For example: “Im going to look after you and do everything that I normally do, but what matters the most to you today?”  Also, there may need to be an acknowledgement of the patient's specific situation, for example in cancer surgery, “I know this is a really big day for you and we are going get you through this but what matters the most to you today?”

    What happened when I tried it?

    I started with trepidation but also interest in whether this would be a worthwhile addition to my usual routine.  I was worried about it coming across as an insincere service industry type “Have a nice day”  and was very careful in the delivery to try and avoid this.  I deliberately asked whether the patients had any questions before I asked them the "what matters" question.  The first patient replied that he hadn’t thought about that before and that he was “here and just wanting to get it done”.  I wondered whether I had rushed the patient and he hadn’t had a chance to think about the question and simply said what first came to mind.  I was a little disheartened initially as it didn’t seem to have utlility but I was determined to continue trying it.  

    I did the same with the second patient and got a completely different repsonse, he said “Well, it’s a bit embarrassing and I’m not sure whether it matters but I’ve been reading about this thing of being awake with muscle relaxant during the surgery and it’s making me really anxious, I didn’t sleep well last night with worry”.  This led into a discussion with him about anaesthetic awareness and the fact that for the surgical procedure and anaesthetic technique he was going to have, the risk was in fact probably less than 1 in 100 000.  Bear in mind that I had already asked whether the patient had any questions and he had said no.

    With such a productive conversation with the second patient, I reflected back on the discussion with the first patient to really consider in context what he had told me.  What I think he was telling me was that he had taken time off work and arranged for someone to be at home with him postoperatively and therefore simply having the procedure was the most improtant thing.  I wasn’t sure whether that would come into any of the decision making but if there was the requirement for a cancellation of one of the patients due to time for example, this could be considered along with clinical need.  


    I think that using this closing question can potentially add to the patient experience in a positive way.  I plan to use it carefully for a few weeks and gauge the response and utility.  This concept has already spread to two other anaesthetists in my department!