Monday, 27 April 2015

Book of the month: Medical error and patient safety: human factors in medicine (Peters & Peters)

About the authors

George and Barbara Peters are a father and daughter team. According to the included biography, George Peters is a multidisciplinary specialist, with experience as a safety specialist and as a design, reliability and quality engineer. Barbara Peters "has specialized in problem solving relating to medical error, safety, risk assessment, and environmental health hazards".

Who should read this book?

The authors state that this book is a basic textbook and reference manual "for those who may attempt to deal with and minimise medical error" (p.6). They go on to say that: "Most readers will have little difficulty understanding the discrete word phrases, simplified specialty language, unique concepts, and general suggestions for the improvement of patient safety by reducing medical error." (p.8) Unfortunately, as explained below, probably very few people should read this book.

In summary

The book is divided into 9 chapters:

  1. Introduction
  2. General Concepts
  3. Medical Services
  4. Medical Devices
  5. Analysis
  6. Human Factors
  7. Management Errors
  8. Communications
  9. Drug Delivery

What's good about this book?

The use of simulators for learning, practice, and refresher training
might help in… emergency, crisis or rare event scenarios (p.20)
The authors mirror Ronnie Glavin's question regarding why there has been so little change since the 1999 report "To Err is Human", saying: "There was no magic remedy, only a seemingly complex and intractable human behaviour problem" (p.2). The authors call for an increase in transparency with respect to medical error, for the harmonisation of standards (e.g. US, EU, international)

The use of simulation and simulators is considered and recommended (e.g. see photo caption) including the use of simulation for resilience or stress-testing "intended to discover and correct weaknesses in the system so that a hardened or more robust organisation will result".

There is the occasional interesting concept, e.g. an "equal status" program instituted at some hospitals in which "all personnel are considered equal and a vital part of the team" (p.23) They also suggest the need for "error detectives" who are authorised to cross organisational boundaries and hierarchies and provide a direct feedback loop to management. The authors also argue for the need for civility and that it should "prevail under normal, stressful, and even extraordinary circumstances." They recommend being honest and advocate the 3R approach (Regret, Reason, Reparation) to apologies. They also call for HF studies to start at the product design stage. Chapter 9, Drug Delivery, covers a number of useful concepts such as the use of warning symbols, labelling, and prescription directions  (such as the slightly unnecessary "Caution: This medicine may be taken with or without food" sticker on a Lisinopril container).

The caveats at the end of each chapter, rather than being caveats actually provide an overview of much of the covered material.

What's bad about this book?

The almost total lack of a narrative or co-ordinated, logical approach to any of the chapters gives this book an "Alice in Wonderland" feel without the great prose. The examples are numerous: 
  • The first sub-heading in "Intentional Bias"(p.15) is "Knee", the next is "Head"
  • In "Chapter 2: General Concepts", "Teamwork" (p.20) is stuck between "Harmonization" and "Rationalisation". 
  • In "Chapter 3: Medical Services", "Innocent Errors" (p.24) is found between "Civility" and "Patient Involvement" (and, no, the headings are not arranged alphabetically)
  • In "Chapter 7: Management Errors", which covers errors due to poor supervision or management decisions, one of the subheadings is "Home Use Devices". This section makes no reference to management.
There is no overview at the beginning of each chapter and although the authors claim to be providing a simplified language they write sentences such as:
"(Factor analysis) is primarily used to test the ranks of number matrices if statistical correlation coefficients are available and express a relationship between the variables" and
"However, there have been dramatic changes or improvements in medical knowledge and procedural skills, medical equipment and devices, pharmaceutical efficacy and safety, higher social expectations from the medical profession, informed consent, animal rights, the intrusion of regulatory and legal concepts of social responsibility, complex payment schemes and practices, and rapid growith of medical organisationss that stress highly interactive group behaviour, financial outcomes, and business goals" (p.108)
 The authors also make sweeping generalisations such as:
"Research has illustrated that there is considerable effort in some areas to locate surface antimicrobial agents" (p.42)
"All (hospital) hardware should be compatible with the limited capabilities of the aged, infirm, sick, and disabled" (p.53)
"Criticism is to be expected during periods of rapid transition. The ideal will become the reality." (p.54)
"Special training may be necessary to prevent situation awareness errors." (p.103)
"A radiating positive attitude should be displayed by managers." (p.140)

Puzzling sentences abound such as "Patients may have special childhood problems such as foreign objects stuck in the throat, respiratory tract, or other body openings. These objects may also include food, bones, nuts, or vegetables not properly chewed" 

And the occasional unnecessary fact is thrown into the mix: "When competing goals, such as fairness versus self-interest, are present, the brain areas involved and activated are the anterior insula and the right dorsolateral prefrontal cortex."(p.149) and "What may be surprising is that long-term potentiation is first induced in the hippocampal area... fast neuron-glia synaptic transmission has been found between CA1 hippocampal neurons and NG2 macroglial synapses" (p.167-168)

Final thoughts

In the Preface, the authors state that they tried to eliminate bias in the book: "There was no third-party direction or control." (p. xvi) Unfortunately this is exactly what the book is lacking, some sort of coordinating entity which might turn this, at times rambling, book into a worthwhile read. The book's title "Medical Error and Patient Safety:  Human Factors in Medicine" seems to have been applied in retrospect and none of the subjects is well-covered. In its present form this book should be given a wide berth.