Not perfect

In the past few weeks, I've managed to lose my keys, my iPhone, and my way, predictable lapses known to occur when a person doesn't sleep or shower in the same place enough. So error, and how to mitigate predictable errror, had been on my mind.

To that end, I now possess 3 identical, well-parsed travel kits, one for home, one for my home away from home, and one for my gym bag. Standardize. Simplify. Before clicking "send," I ask for a second set of eyes on high-stakes transactions (like flight bookings).  Independent double checks. Redundancies.

I know what reduces the chances that simple human error will occur or cause major set-backs in many processes. Last week, I was busy putting this knowledge to work for myself. 

So it seemed like an odd time for counter-intuitive messages--things that show the benefit of imperfection--to crop up. But on Friday morning, I found myself captivated by a story about a mistake. (You can listen to this recollection, made more special because events weren't carried out as planned, in Story Corps' "When the tooth fairy overbooks, helpers step in," a daughter's precious memory of a father's slip.) And today I found Kent Bottles' interesting piece about why failure is important, which called upon a classic article "Teaching Smart People to Learn." (There's a link to the pdf in Kent's post.)

Trying to find the silver lining in the mistake cloud reminds me of a two quotes I used to keep on the bulletin board above my desk: Experience is what you do get when you didn't get what you wanted and Experience helps you recognize when you've made the same mistake twice.

Bon voyage! Safe travels!

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."

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: