Monday, March 23, 2009

A Belief Born of Despair

I've been advocating for solutions to medical error that extend beyond what individuals can do (or can reasonably be held accountable for doing) for a long, long time. In the language of cognitive psychology, this means I ascribe to a system approach for modeling and managing human error.

My belief in system approaches did not arise as a result of study, reflection, or facilitated learning, but came in the aftermath of care my son received in a state-of-the-art children's hospital in 1992. Born with a serious, but fixable digestive problem, my son--and our family--logged more than half of the first year of his life in the hospital.

I've long since forgotten the litany of things that went wrong that year (although equipment malfunction, wound dehiscence, breastmilk mix-ups, tubes that stayed in too long and tubes that came out before their time return to the forefront of my mind after a cursory search of the blessedly faltering "hard drive" where I store these memories). But I have no trouble recalling an evening when I sat in a rocking chair beside my son's crib, meeting with the institution's risk manager who had been called in from home in the aftermath of yet another inexplicable error. "Can you just tell me," I asked in despair, "why the team of seemingly reasonable human beings you represent are so patently unable to render care that does not--in some way, shape, or form--harm my child?"

She could not.

But others have been able to, and over time, I've found solace in some unexpected places. I'm sharing a link to Human error: models and management, a 2000 commentary by James Reason that appeared in the British Medical Journal. This work remains the de facto starting point for anyone interested in the science of reducing human error.

The process of resolving feelings about what happened in the aftermath of my son's difficult start was complex, and I'm sharing just a part of that journey. It's telling that Reason's words--written years after my son's birth--resonated with me, helping to express what I intuitively knew. I hope they will be helpful to you.

I was first able to give up the idea that "bad" (think: careless, stupid, lazy, inconsiderate, incompetent) people were responsible for all that went wrong by considering the problem logically: it was statistically unlikely that our family would have had the bad luck to bump into a disproportionate number of mal-equipped, mal-intended, or simply "off-their-game" individuals with a frequency that could account for the host of significant mishaps that befell us. This analysis may not come to your mind if you seek care once in awhile and have an unsatisfactory encounter or uncover a near-miss. But when you get a data set like the one I had in 1992, you come to realize that some norms, like poor penmanship and ambiguous orders, breed the predictable mishaps that follow.

In my son's case, I ultimately concluded that given the variables of "inpatient days logged" and "complexity of care," he probably experienced the same number of adverse events that anyone else in his situation did. Seeing our misfortunes as a series of unacceptable, but common, outcomes helped me get rid of the feeling that my family was being trailed by some dark cloud of bad juju.

The memory of thoughtful words and genuine acts of kindness also helped dispel the notion that errors in my son's care arose largely because of uncaring or negligent people. In our darkest days, following a leak in my son's newly repaired esophagus, the surgeon shared that he prayed for Luke and for our family, expressing his hope for healing, comfort, and restoration of our family life. The rotating resident brigade, whom I unkindly referred to as the "sneakered sycophants," nevertheless tagged my son with some endearing nicknames, a few that we still use today. One of Luke's home care nurses became a godmother. I share the healing power of these moments, not because I think that intending to do the right thing and actually doing something right are the same. They're not. But these moments helped me see that what was lacking in the care my son received simply couldn't be explained by factors under the control of one individual.

I hope you'll return to this discussion ready to explore more about what turns intention into outcomes, what heals without first hurting. Let me leave you with something that always make me smile:


Kristine said...

Awww...what great pictures!

At the start of my infertility struggles an HSG was done on me. Second time, different doctor. In short, he left part of the catheter in me and I "delivered" it about 12 hours later. When I called him to find out what was going on, he made a joke out of it, promising me nothing else was going to "fall out." I'm still not sure if he knew he left it in their or not.

This was in the beginning of my journey learning about medication safety, errors, and systems approaches, so I knew "some" things, but it was before my work with ISMP.

To this day it still upsets me that the doctor made a joke of it instead of expressing concern, regret, etc. All I needed from him was an "I'm sorry, come in tomorrow and we'll check things out, even though I'm sure everything is fine."

I understand how and why it happened, but I could never really forgive the response to it. And it was ONE incident, that other than losing trust in this doctor, did not harm me.

I can see how during that time with Luke you would think the bad "juju" was getting you. I can also imagine how hearing his doctor tell you he was praying for him must have been incredibly powerful.

Not the most important piece of this type of discussion, but I think something many practitioners forget, is the importance of emotional healing when something does go wrong.

Barbara Olson, MS, RN, FISMP said...

Thanks, Kristine. The rapport I had with Luke's surgeon was remarkable, although it was a relationship neither of us cherished at the time. His candor and ability to communicate that he knew we found it hard to be a family, that I found it hard to be the mother of a seemingly perpetually hospitalized infant kept me from losing my sanity.

The surgical residents added another category to their morning rounds that year, including "How is the family doing?" with the other important things to consider about sick infants.

We also unknowingly pioneered the "rapid response team" concept, an intervention that evolved when I tapped the same problem-solving skills I used at home (place a call to the surgeon's answering service with a request for a call-back) to address significant concerns about how things were unfolding in the hospital. (But that's a story for another day!)

Luke's surgeon put a face to the notion of "good people working in a bad system," and his humility eased some of the burden we carried that year. Thanks for helping me remember to say this here.

Nancy Curdy said...

Barbara, thanks so much for sharing your heartfelt story. Like you, I continue to seek answers to the system issues for our failures to render 100% reliably safe care. My prayer each day is that we'll all have the energy to continue to "fight the good fight" and make important differences in our patients' lives. Always so good to connect with you and our common bond. And so glad Luke became a hungry baby! :) Hugs...Nancy King Curdy

Barbara Olson, MS, RN, FISMP said...

Thanks, Nancy! It's been nice for me to find a new bag of tools that might actually help solve these problems! Luke didn't realize exactly how hard his start had been, so it's been good to be able to share more with him from this distance out. Take care!

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