One might ask, why start a blog on patient safety with such
a negative word? Answer: the
recognition that everyone is fallible is the key to improving patient safety
and quality. There is great wisdom in
the short title of the seminal Institute of Medicine report on reducing
preventable medical errors: To
Err is Human. Yet, 15 years later, some
have still not grasped the meaning of this powerful concept.
I cannot tell you how many health care professionals, mostly
physicians, but also nurses, physician assistants, etc., have related to me that
they do not make mistakes. “I do not
have complications” one surgeon declared.
“They are known outcomes; they are not related to my care.” While some complications are “known” they
occur for varied reasons: systems
issues, human factors, and technical errors. Knowing that
the incidents happen offers the opportunity to understand why they happened and
potentially decrease the chance of them happening again. This is the case whether they are a known or novel
complication.
One example... Infections that result
from the placement of central lines (central line associated blood stream
infections or CLABSIs)
have always been a known complication. For a long time they were accepted and not
reported or tracked. What we have learned though
analysis is that many, if not all of these “known” complications can
be prevented by modifying systems and paying attention to commonly overlooked human factors. It all started with admitting that we are
fallible.
Another example of this behavior pertains to second
opinions. Patients always have the right to all of the information and being comfortable with the plan of
action. In a recent
interview for Forbes, Marty Makary, MD noted that patients, when they are “going
to have a major operation or start taking a potent medicine every day for the
rest of your life…have a right and a duty to know what you’re getting into and
what the options are.” If they are not
comfortable, or do not feel that they have all the information; they have every right to a second opinion. Additionally, I
like his notion that patients have a duty to be engaged. Physicians must not discourage second opinions. The need for a second opinion only reflects poorly on the physician if they are not comfortable with fallibility. One is not always right! Physicians should
embrace the fact that patients are engaged and not judge them negatively for
wanting to be comfortable with a decision that will alter their life.
Finally, for health care teams to be successful, each member
of the team must acknowledge their own fallibility. They must also appreciate that all
members of the team are fallible.
Nowhere is this truer than the use of checklists. Much has been written on checklists,
including a recent study
from Canada published in the New
England Journal of Medicine and two commentaries on the study from Lucian Leape, MD
and AtulGawande,
MD. Checklists help to protect us
from our fallibility. This seems to be clear
to most. But for checklists are to work
as they are intended, we must embrace that we are all fallible. How is this so? To appropriately answer each question on a
checklist, one must assume the negative response and prove the positive
response. Why? If this is not the case, checklists become
the “box
checking” bemoaned by many. If we
simply go through the motions, negatives get checked as positives and the
checklist doesn't do its job. The
checklist protects nothing.
Concomitantly, checklists need to be transacted with teams - meaning more than one person. Each team member must recognize that the other member(s) are fallible. Without this bias, the double check does not
serve a purpose. Finally, if any member
does not believe that an answer is affirmative, they are obligated to raise their
hand and “stop
the line.” A culture that accepts
everyone’s fallibility also accepts the ability to collectively get the answer
right without repercussion.
Patient safety begins with providers recognizing that errors
happen. One cannot solve a problem that
is not believed to exist. Errors happen
because we are all fallible. If we work
collectively within ever improving systems of care, we can protect
patients from this reality and create a truly safe, reliable patient
environment.
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