How Mistakes Can Save Lives
June 6, 2014 1:24 PM Subscribe
What hospitals can learn from flight safety measures. After his wife died due to a mistake during a very simple procedure, Martin Bromiley decided to use his pilot experience to examine how such mistakes can be avoided in the future. It involves changing the whole hierarchy of the hospital environment.
Interesting, this approach was also treated at some length in the New Yorker in 2007.
posted by sandettie light vessel automatic at 1:29 PM on June 6, 2014 [1 favorite]
posted by sandettie light vessel automatic at 1:29 PM on June 6, 2014 [1 favorite]
Related: a brief talk by Capt. Sullenberger (of "Miracle On The Hudson" fame) on how aviation safety compares to hospital safety.
"You probably know in health care right now, including hospital- and health-care-acquired conditions and errors, two hundred thousand lives are lost in this country alone every year. That's twenty jumbo jets a week crashing with no survivors."posted by mhoye at 1:32 PM on June 6, 2014 [13 favorites]
Very interesting, thank you.
posted by the man of twists and turns at 1:39 PM on June 6, 2014 [2 favorites]
posted by the man of twists and turns at 1:39 PM on June 6, 2014 [2 favorites]
Glad to see this. I'm trouble shooting my health (and my kids') the way I troubleshoot software (except for nuking from orbit and reinstalling the ego and the id) good to see it formalized and reapplied to other bits of life (from the airplane folks) and I have go to ways to not reinvent the wheel.
posted by tilde at 1:40 PM on June 6, 2014
posted by tilde at 1:40 PM on June 6, 2014
I kind of wonder whether Gawande's test pilot checklist analogy is because of this guy or if Dr Pronovost was also describing it that way when he came up with his checkilst.
posted by BrotherCaine at 1:50 PM on June 6, 2014 [2 favorites]
posted by BrotherCaine at 1:50 PM on June 6, 2014 [2 favorites]
Really good article.
It's interesting that there's such a cultural difference between alpha dog pilots and alpha dog surgeons - where the former places more of an emphasis on team and checklists, on recognition that they make mistakes, too.
Speaking as someone who spends a great deal of time fixing, preventing, and convincing others that the problems that land on my desk are indeed also their problem - I've got a pretty good hunch on where that difference comes from.
In contrast to surgeons, when pilots fuck up - it's not just the customers that are going to die.
posted by NoRelationToLea at 2:22 PM on June 6, 2014 [11 favorites]
It's interesting that there's such a cultural difference between alpha dog pilots and alpha dog surgeons - where the former places more of an emphasis on team and checklists, on recognition that they make mistakes, too.
Speaking as someone who spends a great deal of time fixing, preventing, and convincing others that the problems that land on my desk are indeed also their problem - I've got a pretty good hunch on where that difference comes from.
In contrast to surgeons, when pilots fuck up - it's not just the customers that are going to die.
posted by NoRelationToLea at 2:22 PM on June 6, 2014 [11 favorites]
If you read the article, it actually mentions the Checklist as another thing that the healthcare industry has borrowed from aviation, but this is distinct from that. In particular, there is an emphasis on learning how to communicate, and how to deal with hierarchy that checklists don't delve into. It talks about how doctors (or anyone really) tend to get fixated on the problem at hand, and don't think about other important things. At this point, there is usually someone else in the room who is thinking about those other things, but they tend not to say anything, because of hierarchy and the belief that the people in charge are aware of those things too. So it's more about how to foster good communication and a culture of speaking out than about checklists per se. Very interesting article.
posted by peacheater at 2:48 PM on June 6, 2014 [7 favorites]
posted by peacheater at 2:48 PM on June 6, 2014 [7 favorites]
At least for emergency medicine I think a better analogy is:
A self-trained pilot has been in flying of a single seater plane for the past fifty or more years; its a DIY job that was built using a very common kit, but the pilot has made some individual modifications that aren't documented anywhere. The maintenance and repair schedules have been poorly documented; the plane has been making funny noises and has handled awkwardly for the past few years; the pilot has been flying on, trying not to pay attention; today, while flying a routine flight, one engine quits, and the other engine is smoking; the plane is losing altitude; in the cockpit lights are flickering on and off, there's a burning, acrid smell; the pilot is coughing and gagging; as the plane descends lower and lower the pilot calls the control tower and says "Take over", and loses consciousness.
What I find amazing is that so many of those pilots survive!
posted by v-tach at 2:51 PM on June 6, 2014 [1 favorite]
A self-trained pilot has been in flying of a single seater plane for the past fifty or more years; its a DIY job that was built using a very common kit, but the pilot has made some individual modifications that aren't documented anywhere. The maintenance and repair schedules have been poorly documented; the plane has been making funny noises and has handled awkwardly for the past few years; the pilot has been flying on, trying not to pay attention; today, while flying a routine flight, one engine quits, and the other engine is smoking; the plane is losing altitude; in the cockpit lights are flickering on and off, there's a burning, acrid smell; the pilot is coughing and gagging; as the plane descends lower and lower the pilot calls the control tower and says "Take over", and loses consciousness.
What I find amazing is that so many of those pilots survive!
posted by v-tach at 2:51 PM on June 6, 2014 [1 favorite]
This is an interesting article and it makes me feel a good bit more sympathetic to the idea of CRM in healthcare. My previous exposure to the concept had been in the form of an all-day lecture/workshop during nursing school, in which a former pilot and professional speaker told us story after story about terrible aviation disasters that could have been prevented if pilots had listened to their crew members or created a more open environment in which criticism could be voiced, and then told us how we needed to be better at communicating with doctors to avoid this problem.
There were no doctors or medical students present, and it just seemed like the whole problem of communication in healthcare was being dumped on us as nurses, with little acknowledgment or understanding of the difficulties of speaking up when you are on the lower branches of the hierarchy. This came the week after I was written up at one of my clinicals for politely telling a surgeon that he could not give a verbal medication order in a non-emergency setting just because he didn't feel like putting it in the computer (which is not only a safety issue, but was a clear violation of institutional policy and state law). But, you know, I was a nursing student so obviously my bad. And then here we were being sat down and told that patients were going to die if we didn't figure out the exact right way to communicate with people who don't want to listen to us.
It's good to see that surgeons, anesthesiologists, etc. are being targeted with these kinds of reforms, and that my experience was a pretty major corruption of the principles of CRM.
posted by bookish at 3:10 PM on June 6, 2014 [22 favorites]
There were no doctors or medical students present, and it just seemed like the whole problem of communication in healthcare was being dumped on us as nurses, with little acknowledgment or understanding of the difficulties of speaking up when you are on the lower branches of the hierarchy. This came the week after I was written up at one of my clinicals for politely telling a surgeon that he could not give a verbal medication order in a non-emergency setting just because he didn't feel like putting it in the computer (which is not only a safety issue, but was a clear violation of institutional policy and state law). But, you know, I was a nursing student so obviously my bad. And then here we were being sat down and told that patients were going to die if we didn't figure out the exact right way to communicate with people who don't want to listen to us.
It's good to see that surgeons, anesthesiologists, etc. are being targeted with these kinds of reforms, and that my experience was a pretty major corruption of the principles of CRM.
posted by bookish at 3:10 PM on June 6, 2014 [22 favorites]
"Doctors make mistakes. A woman undergoing surgery for an ectopic pregnancy had the wrong tube removed, rendering her infertile. Another had her Fallopian tube removed instead of her appendix. A cardiac operation was performed on the wrong patient. Some 69 patients left surgery with needles, swabs or, in one case, a glove left inside them. These are just some of the incidents that occurred in English hospitals in the six months between April and September 2013." (emphasis mine)GAH! I knew there were mistakes, but these blunders occurred over a very short time period. Wow.
posted by joseph conrad is fully awesome at 3:19 PM on June 6, 2014 [1 favorite]
There have been some changes during my lifetime. About the time I was in high school (late 1960's) there was a woman who died on the operating table during what should have been a routine operation. It turned out that some idiot had attached a bottle of nitrogen on the oxygen line, and she suffocated.
After that, two things were done. First, the connectors on oxygen bottles was changed to be incompatible with any other kind of gas bottle, so that it was physically impossible to connect a non-oxygen bottle to an oxygen line. Second, the anesthesia consoles were upgraded to include oxygen sensors on the oxygen line, to alert the anesthesiologist if there was a problem with the oxygen.
There was also a pretty high profile case where someone had a diseased kidney and a healthy one, and went in to get the diseased one removed. Unfortunately, the doctor was careless about which side he operated on, and he removed the healthy one.
After that, now in most hospitals for operations like that, a nurse uses a marker pen to write "Wrong" and "Right" (or "No" and "Yes", or something equivalent) on the two sides of the patient's body, up in his room, before he's taken to the operating room. Often it's checked several times by different nurses to make sure it's marked correctly.
posted by Chocolate Pickle at 3:43 PM on June 6, 2014
After that, two things were done. First, the connectors on oxygen bottles was changed to be incompatible with any other kind of gas bottle, so that it was physically impossible to connect a non-oxygen bottle to an oxygen line. Second, the anesthesia consoles were upgraded to include oxygen sensors on the oxygen line, to alert the anesthesiologist if there was a problem with the oxygen.
There was also a pretty high profile case where someone had a diseased kidney and a healthy one, and went in to get the diseased one removed. Unfortunately, the doctor was careless about which side he operated on, and he removed the healthy one.
After that, now in most hospitals for operations like that, a nurse uses a marker pen to write "Wrong" and "Right" (or "No" and "Yes", or something equivalent) on the two sides of the patient's body, up in his room, before he's taken to the operating room. Often it's checked several times by different nurses to make sure it's marked correctly.
posted by Chocolate Pickle at 3:43 PM on June 6, 2014
Dear doctors:
We have noticed positive results by occasionally pulling our heads out of our asses long enough to hear what anyone else in the room is saying. Perhaps you might also benefit from these discoveries. It will be difficult, but it's less expensive this way. Luv, Pilots
posted by bleep at 4:33 PM on June 6, 2014 [7 favorites]
We have noticed positive results by occasionally pulling our heads out of our asses long enough to hear what anyone else in the room is saying. Perhaps you might also benefit from these discoveries. It will be difficult, but it's less expensive this way. Luv, Pilots
posted by bleep at 4:33 PM on June 6, 2014 [7 favorites]
Often it's checked several times by different nurses to make sure it's marked correctly.
I had surgery last year, and every person I encountered from intake until they knocked me out would ask my name and check it against my wristband and their paperwork. Then they'd ask me what I thought I was there for that day, to make sure there hadn't been any miscommunication about the procedure that was to be performed. Then they'd give me a chance to tell them if I had any concerns, and they'd encourage me to repeat those concerns to the surgeon/anesthesiologist/etc.
Each one of these conversations was one-on-one, probably to avoid situations where the person who recognizes the discrepancy is ignored (or fails to speak up at all) due to everyone else's groupthink. It was very reassuring.
posted by Blue Jello Elf at 5:37 PM on June 6, 2014 [3 favorites]
I had surgery last year, and every person I encountered from intake until they knocked me out would ask my name and check it against my wristband and their paperwork. Then they'd ask me what I thought I was there for that day, to make sure there hadn't been any miscommunication about the procedure that was to be performed. Then they'd give me a chance to tell them if I had any concerns, and they'd encourage me to repeat those concerns to the surgeon/anesthesiologist/etc.
Each one of these conversations was one-on-one, probably to avoid situations where the person who recognizes the discrepancy is ignored (or fails to speak up at all) due to everyone else's groupthink. It was very reassuring.
posted by Blue Jello Elf at 5:37 PM on June 6, 2014 [3 favorites]
Dear doctors:
We have noticed positive results by occasionally pulling our heads out of our asses long enough to hear what anyone else in the room is saying. Perhaps you might also benefit from these discoveries. It will be difficult, but it's less expensive this way. Luv, Pilots
Dear Pilots,
We are doing our best to listen to constructive feedback and not let ego get the better of us, nor repeat the errors of previous generations of doctors. Thanks,
Medical Students
posted by kurosawa's pal at 6:07 PM on June 6, 2014
We have noticed positive results by occasionally pulling our heads out of our asses long enough to hear what anyone else in the room is saying. Perhaps you might also benefit from these discoveries. It will be difficult, but it's less expensive this way. Luv, Pilots
Dear Pilots,
We are doing our best to listen to constructive feedback and not let ego get the better of us, nor repeat the errors of previous generations of doctors. Thanks,
Medical Students
posted by kurosawa's pal at 6:07 PM on June 6, 2014
If you read the article, it actually mentions the Checklist as another thing that the healthcare industry has borrowed from aviation, but this is distinct from that. ... it's more about how to foster good communication and a culture of speaking out than about checklists per se.
I've read the Checklist Manifesto and it covers this exact topic of dealing with hierarchy and encouraging nurses to speak up about "obvious" things. It is not just a book about using a checklist.
posted by the agents of KAOS at 6:16 PM on June 6, 2014
I've read the Checklist Manifesto and it covers this exact topic of dealing with hierarchy and encouraging nurses to speak up about "obvious" things. It is not just a book about using a checklist.
posted by the agents of KAOS at 6:16 PM on June 6, 2014
Can anyone say ... Pilot's Disease? *rimshot*
Jokes aside, this is a great article. I think it's interesting to think about those human factors in pretty much every work environment: I'm not in medicine any more, but the software company I work for is just as bad as a hospital in terms of fixation error, time perception and hierarchy from what I can tell.
posted by pulposus at 8:07 PM on June 6, 2014 [2 favorites]
Jokes aside, this is a great article. I think it's interesting to think about those human factors in pretty much every work environment: I'm not in medicine any more, but the software company I work for is just as bad as a hospital in terms of fixation error, time perception and hierarchy from what I can tell.
posted by pulposus at 8:07 PM on June 6, 2014 [2 favorites]
What an amazing article. It's absolutely fascinating to me that his response to this terrible personal tragedy was to quietly and efficiently work for change. This guy is a hell of a human being.
posted by feckless fecal fear mongering at 9:44 PM on June 6, 2014 [7 favorites]
posted by feckless fecal fear mongering at 9:44 PM on June 6, 2014 [7 favorites]
I just want to point out that this article is about the UK.
At least in the US, patient safety is something that is taken very seriously during the hospital accreditation process by the Joint Commission. Before every procedure in the OR, there is a timeout where the nurses, anesthesiologists, and surgeons confirm the patient's name, DOB, and the specific location of the procedure being done. Before the start of a case and before the skin is closed, the OR nurses & techs account for all of the towels, instruments, suture needles, etc. used. If there is a discrepancy, imaging is obtained intra-op to make sure nothing is left behind.
The larger point of improved teamwork and communication especially in mission-critical situations is indeed something that is being emphasized at medical schools in the US. Because of the work hour restrictions of residency, there are more patient handoffs between teams covering different times of the day. Clear and efficient communication of crucial clinical information during the handoff process between the teams go a long way towards making sure that these patient handoffs are safe. Based on my experience so far, we are getting a good dose of these skills during medical school in preparation for residency and beyond.
posted by scalespace at 10:08 PM on June 6, 2014
At least in the US, patient safety is something that is taken very seriously during the hospital accreditation process by the Joint Commission. Before every procedure in the OR, there is a timeout where the nurses, anesthesiologists, and surgeons confirm the patient's name, DOB, and the specific location of the procedure being done. Before the start of a case and before the skin is closed, the OR nurses & techs account for all of the towels, instruments, suture needles, etc. used. If there is a discrepancy, imaging is obtained intra-op to make sure nothing is left behind.
The larger point of improved teamwork and communication especially in mission-critical situations is indeed something that is being emphasized at medical schools in the US. Because of the work hour restrictions of residency, there are more patient handoffs between teams covering different times of the day. Clear and efficient communication of crucial clinical information during the handoff process between the teams go a long way towards making sure that these patient handoffs are safe. Based on my experience so far, we are getting a good dose of these skills during medical school in preparation for residency and beyond.
posted by scalespace at 10:08 PM on June 6, 2014
There is a chapter in the book "The Power of Habit" about a fire in the London Underground that killed 31 people. The book describes how key people that could have prevented the tragic outcome didn't act strongly enough upon discovering the fire, or in prevention of fires in general, because it wasn't their department and they weren't supposed to step on any toes (the blame is not lied on those people, but on the organization that created that culture). I found it a chilling read and also really recognizable in other organizations.
The key takeaway from the book was that eventually the investigator for this fire turned it into a big media circus so that the Underground was forced to really changed policies. A sense of crisis is necessary to really get organizations to really change a lot, according to the book. Just someone higher up ordering it is not enough. The challenge in health care is, I guess, that nobody views medical errors as a crisis.
posted by blub at 2:04 AM on June 7, 2014 [1 favorite]
The key takeaway from the book was that eventually the investigator for this fire turned it into a big media circus so that the Underground was forced to really changed policies. A sense of crisis is necessary to really get organizations to really change a lot, according to the book. Just someone higher up ordering it is not enough. The challenge in health care is, I guess, that nobody views medical errors as a crisis.
posted by blub at 2:04 AM on June 7, 2014 [1 favorite]
Medical errors are very much a problem in the US, despite major efforts in recent years to address them. See this for example. Progress is certainly being made, and organizations are changing the way they operate, but I think it's a mistake to consider this a UK problem.
In my experience, hospitals vary tremendously in how safety-conscious they are and how open and communication-friendly their environments are. Teaching hospitals tend to be better than other institutions-- they are the hospitals paying close and careful attention to innovations and reforms in all aspects of health care. But I have seen abuses of power in them, too.
It can really take a long time to make changes in institutional culture. People who have been conditioned over years to not speak up because of fears of ridicule and reprisal aren't going to feel comfortable changing right away. Similarly, doctors and other higher-ups in the system who are good people and genuinely listen to their team members often don't realize the degree to which people are holding back because of their experiences with other doctors, etc. You see this when you ask nurses and doctors to rate the quality of collaboration and communication within their units-- doctors generally rate it as much higher than nurses do.
posted by bookish at 9:14 AM on June 7, 2014 [2 favorites]
In my experience, hospitals vary tremendously in how safety-conscious they are and how open and communication-friendly their environments are. Teaching hospitals tend to be better than other institutions-- they are the hospitals paying close and careful attention to innovations and reforms in all aspects of health care. But I have seen abuses of power in them, too.
It can really take a long time to make changes in institutional culture. People who have been conditioned over years to not speak up because of fears of ridicule and reprisal aren't going to feel comfortable changing right away. Similarly, doctors and other higher-ups in the system who are good people and genuinely listen to their team members often don't realize the degree to which people are holding back because of their experiences with other doctors, etc. You see this when you ask nurses and doctors to rate the quality of collaboration and communication within their units-- doctors generally rate it as much higher than nurses do.
posted by bookish at 9:14 AM on June 7, 2014 [2 favorites]
On one hand you have a completely broken healthcare system, but that's another topic.
I would love it if we had mandatory quality assurance measures for healthcare. I think that a lot of the doctors in practice are focusing on getting paid, and jumping through the insurance company hoops. That's wasted time and effort in terms of patient outcomes.
On the other hand I'm afraid that a system of quality control and accountability would suffer from massive mission creep, "like everything else the gummint touches," as I recently heard a colleague say; and we would have thousands of various bureaucratic functionaries micromanaging everything I do with implementing pointless metrics that have no basis in the actual science.
So I'm torn. But I would rather err on the side of screwing me over then the current situation where thousands of people die every year because of idiotic mistakes and an senselessly abusive medical culture.
I've given up on anything really changing until we get single-payer. Which won't happen in my lifetime.
posted by hobo gitano de queretaro at 12:45 PM on June 7, 2014
I would love it if we had mandatory quality assurance measures for healthcare. I think that a lot of the doctors in practice are focusing on getting paid, and jumping through the insurance company hoops. That's wasted time and effort in terms of patient outcomes.
On the other hand I'm afraid that a system of quality control and accountability would suffer from massive mission creep, "like everything else the gummint touches," as I recently heard a colleague say; and we would have thousands of various bureaucratic functionaries micromanaging everything I do with implementing pointless metrics that have no basis in the actual science.
So I'm torn. But I would rather err on the side of screwing me over then the current situation where thousands of people die every year because of idiotic mistakes and an senselessly abusive medical culture.
I've given up on anything really changing until we get single-payer. Which won't happen in my lifetime.
posted by hobo gitano de queretaro at 12:45 PM on June 7, 2014
OTOH in the grand tradition of zero tolerance the US has declared injury due to any falls in hospitals a "never event" like amputating the wrong limb.
How do you prevent people from falling down? Once you've done the appropriate stuff with handrails, non-slip surfaces, etc., etc., but sometimes people still fall down, you move onto discouraging them from getting out of bed, chemical sedation, and restraints.
posted by save alive nothing that breatheth at 4:39 PM on June 7, 2014 [2 favorites]
How do you prevent people from falling down? Once you've done the appropriate stuff with handrails, non-slip surfaces, etc., etc., but sometimes people still fall down, you move onto discouraging them from getting out of bed, chemical sedation, and restraints.
posted by save alive nothing that breatheth at 4:39 PM on June 7, 2014 [2 favorites]
Huh. I've noticed 'fall prevention' stuff happening seemingly out of nowhere at a couple hospitals here over the past couple of years. Low-hanging fruit maybe?
posted by feckless fecal fear mongering at 5:36 PM on June 7, 2014
posted by feckless fecal fear mongering at 5:36 PM on June 7, 2014
OTOH in the grand tradition of zero tolerance the US has declared injury due to any falls in hospitals a "never event" like amputating the wrong limb.
Yep, and this is profoundly stupid. Some of the "never events" make a lot of sense, like retention of foreign bodies after surgery or giving a patient the wrong blood type. But although there are measures that can reduce fall rates, like adequate staffing and regular rounding, there's no way to completely stop them. Right now there is a lot of money being thrown at the problem, since hospitals now must foot the bill for injuries incurred as a result of falls, but still no one has managed to come up with a solution that actually works.
It's not so much low-hanging fruit as it is a mad scramble to find something, anything to get fall rates down. Hospitals keep trying new stuff, which can be really trying for the people who have to implement the plans. One of the unfortunate results is a lot of pressure to do things like sedate patients or use restraints, both of which can cause real harm to patients.
posted by bookish at 7:24 PM on June 7, 2014 [1 favorite]
Yep, and this is profoundly stupid. Some of the "never events" make a lot of sense, like retention of foreign bodies after surgery or giving a patient the wrong blood type. But although there are measures that can reduce fall rates, like adequate staffing and regular rounding, there's no way to completely stop them. Right now there is a lot of money being thrown at the problem, since hospitals now must foot the bill for injuries incurred as a result of falls, but still no one has managed to come up with a solution that actually works.
It's not so much low-hanging fruit as it is a mad scramble to find something, anything to get fall rates down. Hospitals keep trying new stuff, which can be really trying for the people who have to implement the plans. One of the unfortunate results is a lot of pressure to do things like sedate patients or use restraints, both of which can cause real harm to patients.
posted by bookish at 7:24 PM on June 7, 2014 [1 favorite]
I watched in admiration as an ICU nurse told an attending physician
I think the key here is that it was an ICU nurse. ICU nurses tend to get taken alot more seriously by doctors than other nurses because they know their stuff (this is not a knock on other types of nurses, I have alot in my family and they are all so very very smart regarding medical stuff). The ICU nurses are given no more than 2 or 3 patients to look after because serious stuff happens in the ICU and the nurses are there to act before the doctors can even get there to give the orders.
posted by LizBoBiz at 9:05 AM on June 9, 2014 [1 favorite]
I think the key here is that it was an ICU nurse. ICU nurses tend to get taken alot more seriously by doctors than other nurses because they know their stuff (this is not a knock on other types of nurses, I have alot in my family and they are all so very very smart regarding medical stuff). The ICU nurses are given no more than 2 or 3 patients to look after because serious stuff happens in the ICU and the nurses are there to act before the doctors can even get there to give the orders.
posted by LizBoBiz at 9:05 AM on June 9, 2014 [1 favorite]
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The Checklist Manifesto
posted by C.A.S. at 1:28 PM on June 6, 2014 [17 favorites]