Thursday, 7 September 2017

What's in your attic?

This blogpost weaves together 4 threads:
1) In Oscar Wilde's only novel, "The Picture of Dorian Gray", Dorian sells his soul to ensure that a portrait of him ages while he remains young. 

2) In his must-read book "Safe Patients, Smart Hospitals" Peter Pronovost argues that healthcare professionals are very good at hiding mistakes from themselves. They compartmentalise mistakes and explain them away because of a belief that "doctors don't make mistakes."

3) In a very good lecture, Scott Weingart argues that:

"The difference between bad doctors and good doctors is not that the bad ones make a bad decision every single shift or even every single week. The difference between a bad doctor and a good doctor may be one bad decision a month. And that's really hard to get self-realised feedback on. There are not enough occurrences of real, objective badness to learn from one's mistakes."

4) Lastly, if we take the numbers from the Instititute of Medicine's "To Err is Human" as correct then we can postulate the following: 
  • There are approximately 100,000 deaths due to medical error per year in the US (1)
  • There are approximately 500,000 doctors in the US (2)
  • Therefore a given doctor will be involved in a death due to medical error once every 5 years
  • Let us make the assumption that only 50% of these deaths are recognised as having been caused by medical error. Then a given doctor will be aware of a patient who died in part due to his/her medical error once every 10 years.  Or 4 deaths per career.

Now for the weaving. 

For a number of reasons healthcare professionals will not be able to have a good understanding of their actual performance. Partly this is because our involvement in errors leading to death is (thankfully) rare and partly because the feedback loop in healthcare is often very long or non-existent. 

We are also, because we are human, very good at rationalising our poor performance. Lastly many of our jobs require confidence, or at least an outward confidence, in order to believe that we can do the job and to put patients at ease. 

This means that, like Dorian Grey, we have a public persona which is confident, capable and error-free. But we also have our "true" selves hidden away, perhaps not as pretty as we might like to think. 

If this is a problem then what are the solutions? 

Unsurprisingly perhaps, given that this is a simulation & HF blog, one solution is immersive simulation. The simulation has to be realistic enough to trigger "natural" behaviour and actions. Realisation of the differences between one's imagined and actual performance  often emerge as the simulation progresses. The simulation can also create the conditions under which poor decisions are more likely to be made. This means rather than waiting a month for a sufficiently stressful real-life event to occur, twelve stressful scenarios can be created in a day.

However it is during the debrief that the two personas, the portrait and the person, can be compared. The use of video-based debriefing means that the participant can see their own performance from an outsider's perspective. The facilitator helps the participant see the metaphorical wrinkles and scars that have accumulated over time. The skilled facilitator provides help in taking ownership of the blemishes and advice on how to work on reducing them.

Simulation remains overwhelmingly the domain of the healthcare professional "in training". Consultants, staff grades, registered nurses, midwives and other fully qualified professionals rarely cross the threshold. Perhaps this is because in training the portrait of ones true self is constantly being exposed. It hangs, as it were, above the fireplace or in a prominent position where many people can and do comment on it. Upon completion of training it is with a sense of relief that the portrait is relocated to the attic. And the longer it stays up there, the greater the fear of the horror we will be faced with if we take it back down.

Face your fears, attend a simulation session and let's clear out that attic together. 

1) DONALDSON, M. S., CORRIGAN, J. M. & KOHN, L. T. 2000. To err is human: building a safer health system, National Academies Press.
2) Number of active physicians in the U.S. in 2017, by specialty area (Accessed 7/9/17)

Monday, 17 April 2017

Translating simulation into clinical practice: Psychological safety

At our sim centre, safety is a key concern. When people mention safety in the context of simulation, the first thought is often the safety of the patient. Simulation is safe for patients because, in the majority of cases, lack of patient involvement means that no patient is harmed. Perhaps the second thought regarding patient safety is that this is one of the reasons we carry out simulation in the first place.

Safety is not just about the patient however, but also about the simulation participant. In terms of physical safety, at our sim centre we have had sharps injuries, slips and trips, as well as a defibrillation of a mannequin while CPR was in progress. So, physical safety is important.

However, we think that the psychological safety of the participants is as important as their physical safety. Psychological safety “describes perceptions of the consequences of taking interpersonal risks in a particular context such as a workplace” (Edmondson & Lei 2014).  When people feel psychologically safe they will be more willing to speak up, to share their thoughts, and to admit personal limitations. This means that psychological safety is important not just in simulations but also in clinical practice.

The psychologically safe simulation environment is not self-generating, it must be created and sustained by the facilitator and participants. Creating this environment is not a cryptic, mystical feat which is only achieved by the expert few, but rather a set of behaviours and actions which can be learned. This means that the lessons learnt from creating psychological safety in simulation can be translated into clinical practice. Key concepts are:
  • Flatten the hierarchy
  • Prime people that mistakes will be made
  • Set an expectation of challenging observable behaviours/actions
  • Stress confidentiality

Flatten the hierarchy

A hierarchy is evidenced by a power distance or authority gradient where certain people are placed “above” others usually as a result of additional training or skills. A hierarchy, with defined leadership, is essential for safe care. However when the authority gradient is very steep those lower down are less likely to challenge behaviour. In aviation this has contributed to a number of well-publicised crashes including the Tenerife disaster. In healthcare it results in leaders making fatal (for the patient) mistakes without members of their team speaking up to correct them.

Flatten the hierarchy:
            In the daily brief by:
            Ensuring everyone introduces themselves
Ensuring everyone introduces themeselves by their first name
Admitting to personal fallibility
Setting the tone of expected respect

During the day by:
Gently correcting colleagues who use your title to refer to you by first name
Protecting those at the bottom of the authority gradient from bullying, harassment or other demeaning behaviour by others.

Prime people that mistakes will be made

In the simulated environment mistakes are almost guaranteed due to the planned crisis nature of the experience. In clinical practice mistakes cannot be guaranteed but it is unlikely that no mistakes will happen during a typical day. (Where research has been carried out, in paediatric cardiac surgery, there were approximately 2 major compensated events and 9 minor compensated events per operation. (Galvan et al, 2005)) It is therefore essential to prime people at the beginning of the day that mistakes are likely, that this is “normal” and that they should be looking out for them.

Set an expectation of respectful challenge to observable behaviours/actions

You have made it clear that people will make mistakes. You can then therefore set an expectation that others will challenge any behaviour or action which they are unsure about, which they think is a mistake or which they think threatens patient safety. Warn people that when their behaviour or action is under scrutiny that they will feel uncomfortable and perhaps threatened. Reassure people that when they are having these feelings of discomfort that they are experiencing a "learning moment". Either the person raising the concern is correct and a mistake is being averted or they are correct and the person raising the concern can be thanked and the action clarified.

Stress confidentiality

In the simulation environment, with very few exceptions, we can guarantee that the experience will remain confidential with respect to the facilitator (i.e. we will not talk about participant performance after the simulated event is over) and that we expect the same from the participants. In clinical practice a similar promise can be made. Of course errors, particularly those which may recur in other situations, must be reported using the appropriate system in order to help the system learn. However this does not have to be on a naming and shaming basis but rather a collective effort to explain how an error happened, how it was dealt with and how it may be prevented in the future. In addition this is an opportunity to stress that you will not talk about any mistakes behind people's backs or use the reporting system as a weapon to punish people.

Psychological safety and mistakes

Staff psychological safety will improve patient health
One of the concerns that people may have is that the “psychologically safe” unit/team/department will be more tolerant of error and therefore make more mistakes.  In 1996, Amy Edmondson looked at eight hospital units and, with the help of a survey instrument and a blinded observer, rated their psychological safety with respect to medication errors. She found that the more psychologically safe the unit was, the greater the number of errors reported. However, she also found that the more psychologically safe the unit, the fewer medication errors the staff actually made. Units which were not psychologically safe not only reported fewer errors but made more.

Final thoughts

Words shape our thinking and we struggle to discuss a concept if we don't have a name for it. It is time that the term "psychological safety" escapes the confines of the simulation centre and enters clinical practice. We all deserve psychological safety at work and you can help make this a reality by using some of the above tips.


1)   EDMONDSON, A. C. & LEI, Z. 2014. Psychological safety: The history, renaissance, and future of an interpersonal construct. Annual Review of Organizational Psychology and Organizational Behavior, 1, 23-43.

2)   GALVAN, C., BACHA, E. A., MOHR, J. & BARACH, P. 2005. A human factors approach to understanding patient safety during pediatric cardiac surgery. Progress in Pediatric cardiology, 20, 13-20.

3) EDMONDSON, A. C. 1996. Learning from mistakes is easier said than done: Group and organizational influences on the detection and correction of human error. The Journal of Applied Behavioral Science, 32, 5-28.