Wednesday, October 21, 2009

Car dating & cognitive dissonance at Grand Rounds

Here's a link to SharpBrains, where yesterday's host Alvaro Fernandez brought together Grand Rounds (a forum for medical bloggers) and Encephalon (a forum for people who blog about the brain and mind). Alvaro offers a tongue-in-cheek, "What a nice surprise! Hello. Nice to meet you" to both groups.

The introduction has already been made.

The need to recognize the inherent fallibility of humans (and design systems that are reliable in spite of the predictable faux pas humans make) was articulated nearly a decade ago in the first IOM report, To Err is Human. Alvaro's invitation, his need to suggest that healthcare professionals dip into the cognitive psychology well, is telling. It's surely part of the reason we've yet to post measurable gains in preventing inadvertent medical error.

It occurs to me that when introductions lead to a relationship, it's because both parties perceive a benefit. It's been ten years, and in the U.S, we're still discussing whether tired residents are really as tired as other tired people. And entertaining other intention-oriented ideas, like "Follow the 5 Rights." This suggests cognitive dissonance between the safety paradigm we have and the one we need. Apparently, "we're just not into you," SharpBrains.

Healthcare remains distinguished from other high consequence industries by the degree of personal vigilance we tolerate and rely on. No matter where you or your organization may be on the journey toward improving patient safety, you should agree to a second date with the folks who study the performance parameters of humans.

Applying lessons learned to healthcare workers and the systems used to deliver care is a necessary step in eradicating the public health problem called "medical error."


Tom said...

Barb, from the perspective of, say, a front-line nurse or phramacist or rad-tech, what is this "second date", and how does one get an offer, recognize it, and let alone, accept it? Is a more eligible pool of suitors needed? Wow, the metaphor (a great metaphor, I think) is moving into strange places. Sorry.

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

So glad you asked. This is the kind of coaching I like to do. Healthcare workers, most of whom have not been schooled in systems analysis, tend to deconstruct errors/near-misses seeing only the person closest to the undesirable outcome. Therefore, improvement efforts focus only on the last link in a weak chain. (We know this since most error reports from front line leaders list "review policy" or "re-educate nurse" as a corrective measure. This doesn't make them bad people or bad managers, necessarily. But it is an example of "dating who know"- even if the "date" is not your best prospect.) It's common for HC professionals to overestimate the value of education in preventing reoccurrence of errors. (This is seen at the level of professional boards as well as among front line clinicians.) Unfortunately, smart people who know their stuff are often involved in errors and re-education infrequently prevents the next event.(Education/competency is a pre-requisite for a desired outcome, not a guarantee of one.) So instead of sticking with the known entity (educate, re-educate), front line managers should expand their "circle of friends" or "fish in a better pond." I found this today: It's a free primer in mistake-proofing: core information about higher-level risk reduction strategies front line managers benefit from knowing. Material like this is a "must read" to understand what else is out there and give up those old, dysfunctional dating habits.

Tom said...

Perfect! And an excellent denouement to the metaphor. I sure hope you're getting traction out there with the front line. The healthcare system needs you - and more patients will survive if more hc workers key in on your messages.

bellafrau said...

First time visiting your blog but already saved it in favorites! Thanks for the link to the Mistake Proofing article by AHRQ. After your endorsement I'm excited to read it.

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