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. 

Flight 4U 9525 and the dynamic Swiss cheese model

The Swiss cheese model

James Reason's Swiss cheese model explains how successive layers of defences can be breached, or weaknesses can line up, in order for an incident to occur.

The traditional depiction of the model is of a static succession of slices of cheese. In this model, closing one of the holes in the sequence prevents the incident.

A better way of visualising the concept is by thinking of a dynamic Swiss cheese model (see video). The weaknesses are not static and closing one weakness may cause another to open elsewhere in the same (or another) "slice".

Flight 4U 9525

The exact circumstances of the crash of the Germanwings Airbus 320 on the 24th of March 2015 have yet to be established. However it seems likely that the co-pilot intentionally flew the plane into the ground. The captain had probably left the flight deck to use the toilet and was then locked out of the cockpit by his first officer.

Post-9/11 cockpit doors

After the 9/11 terrorist attacks, cockpit doors were reinforced in order to prevent forced access. In terms of the Swiss cheese model, this weakness was therefore reduced. Crew could still access the cockpit if the pilot had become incapacitated by entering a keypad code. However, if the pilot was not incapacitated he or she could override the keypad system. Therefore a terrorist in possession of the code could still be prevented from getting into the cockpit.

The dynamic Swiss cheese model

The closing of the weakness in the structural/system layers allowing terrorists access to the cockpit opened a weakness in the set of circumstances where someone may want to access the cockpit for legitimate reasons against the flight crew's wishes. After the loss of Malaysia Airlines flight MH370, Popular Mechanics wrote a prescient article in March 2014 asking "Could Plane Cockpits Be Too Secure? Should pilots be allowed to lock themselves in the cockpit?" After the crash of Flight 4U 9525, in an attempt to close this new weakness, many airlines are now requiring the presence of two crew members on the flight deck at all times. It is unclear what new weaknesses this policy will create.

Lessons for the rest of us

Measures put in place in response to an incident will almost inevitably increase the risk of other, unforeseen incidents occurring. Time spent carrying out analyses and simulations of possible side-effects of the "fix" may allow us to minimise these new weaknesses.

Book of the Month: Being Mortal (Illness, Medicine and What Matters in the End) by Atul Gawande (Reviewed by Kirsten Walthall @K_Walthall)

About the author

Atul Gawande is a general and endocrine surgeon based at the the Brigham and Women’s Hospital in Boston, USA. Gawande is also a staff writer for The New Yorker magazine and the author of four best-selling books. His latest work, published in late 2014, is titled “Being Mortal: Illness, Medicine and What Matters in the End”.

Who should read this book?

Everyone – healthcare providers, patients and the lay public. Although several issues are highlighted through a case series of patients with medical problems, the book does not focus on the ins and outs of medical matters, such as the specifics of treatments. Gawande’s easy style of writing makes this book accessible to all. 

In summary

This book explores the concept of mortality and the impact that modern day medicine has had on it.

Using a series of cases, Gawande discusses the experiences of several people as they grow old, some with life-limiting diseases and others who simply become frail. He looks at the struggle to retain independence and autonomy; how care systems often try to provide support in a regimented way. Gawande discusses the concept of  “assisted living”, which helps people to continue to live the lives that they have lived. Furthermore, Gawande explores the belief of healthcare professionals that they have failed when a patient dies. Many find it difficult to accept that medicine cannot fix everything, and therefore may give poor information to their patients about what they realistically expect medical management to accomplish. Gawande discusses the importance of having those hard conversations with patients to find out what matters most to each individual so that therapy and care can be tailored to them. He argues that what we should be striving for is maintaining quality of life until death, rather than just prolonging life itself.

What’s good about this book?

Gawande uses #whatmattersmost on Twitter

The use of case studies and personal experiences to explore the issues involved in growing old and dying engage the reader. Gawande’s writing style makes “Being Mortal” very easy to read despite the potentially heavy subject matter. Mortality was not well covered in my undergraduate training – indeed it was barely touched upon – and I suspect that this is the same across the board in undergraduate medical education. This impression is supported by a study by Bowden et al (2013) who found that Foundation Year doctors expressed a lack of readiness to deliver end of life support and care.  “Being Mortal” really makes the reader think about the latter stages of life and the importance of preserving what matters most to each individual. It gives the reader an understanding of mortality that, for the healthcare professional, will benefit her patients and, for the individual, will benefit her, her relatives and her friends.

 

What’s bad about this book?

This is not a quick read book. It is very thought-provoking and encourages discussion - you will need time to read, absorb and think about its contents.

Final thoughts

This is by far the most inspirational and thought provoking book I have read – a must-read for anyone involved in patient care.

Reference

Bowden, J., Dempsey, K., Boyd. K., Fallon. M. and Murray. S.A. (2013) Are newly qualified doctors prepared to provide supportive and end-of-life care? A survey of Foundation Year 1 doctors and consultants, Journal of the Royal College of Physicians of Edinburgh. 43 pp.24-28 [Online] Available at: http://www.rcpe.ac.uk/sites/default/files/bowden.pdf (Accessed: 02 March 2015)

A view from the ivory tower (by M Moneypenny)

Background

On the 21st of February 2015 there was a brief Twitter exchange between Mark Forrest (@Obidoc) and others regarding the benefits of in situ "applied" simulation versus simulation centres. Although the 140 character limit on Twitter ensures thoughts are distilled, at times this can be difficult to lay out an argument. (The benefits and drawbacks listed below are by no means exhaustive.)

The benefits of in situ

The positives of in situ are manifold. By definition, the participants are in the actual environment (in the resus department, on the ward, at the roadside, under a train) which increases environmental fidelity. They are using their own equipment, guided by their own protocols. One can carry out systems testing and, if the simulation is realistic enough, performance approaches actual performance in real life.

The drawbacks of in situ

If the exercise is taking place in the actual environment there is disruption to the rest of the workplace. This can be minimised by good preparation and planning. Because of this disruption, the number of in-hospital in situ exercises is limited.

For those who extol the realism of in situ, running a simulation in a field or country lane is very different from running a simulation on a busy (and aren't they all nowadays?) hospital ward. The pre-hospital in situ equivalent would be running a simulation alongside a major motorway with a lane closed off.

When is in situ not in situ?

The Uaill Scottish Fire & Rescue Service Training Centre in Glasgow, has its own section of motorway and train track. The fire service runs multi-agency mass casualty simulations here. But the centre, and others like it across the UK, cost millions to build. Is this in situ sim?

Our home, but darn it! Why does it have to be a white tower?

The benefits of sim centres

The sim centre's sole function is as a place where simulation exercises take place. Sim centre personnel are dedicated to certain roles e.g. administrative, technical. Because the sim centre's focus is simulation the faculty are often involved in research and the development of other simulation-based medical educators.

The sim centre can be modified to replicate a "generic" ICU, ward, theatre or resus. The sim centre can accommodate hundreds of undergraduates and other trainees every year which would not be possible on a hospital ward.

The drawbacks of sim centres

Building a sim centre is expensive, although if it is built as part of a new hospital this lessens the expense. If a sim centre solely uses mannequins it is limited by what it can replicate and the "generic" ward or ICU means that it is not actually any ward or ICU. Sim centres may become silos if they don't make and sustain links with other stakeholders such as patient representatives, pre-hospital organisations and higher education institutions.

Final thoughts

A straw man(ikin)

The ivory-towered sim temple which sucks up millions of pounds and doesn't do "real simulation, which takes planning and hard work" is a straw man, which no-one would support. The reality is very different, no-one is throwing millions of pounds at us, with every penny justified and accounted for. Sim centres carry out exercises in the centre and in situ, the SCSC^HF has been in the back of ambulances, in hospital wards, in ICU and paediatric resus. We haven't (yet) been out in a field or at the side of the road, primarily because we feel that colleagues (in the fire service, ambulance service, BASICS) already occupy this niche and do a fantastic job. We use the appropriate technique based on the learning objectives of the learners, this may be high technical fidelity mannequins, part-task trainers, iPad-based sim "monitors" or a cardboard box with a 2-litre reservoir bag inside. 

In conclusion, rather than adopting an "us versus them" attitude, the poor in situ practitioners in the trenches throwing mud at the rich, work-shy inhabitants of the ivory towered temples of simulation, I would suggest an approach which involves communication and cooperation.