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Trends in Anaesthesia and Critical Care xxx (2012) 1e5
Contents lists available at SciVerse ScienceDirect
Trends in Anaesthesia and Critical Care
journal homepage: www.elsevier.com/locate/tacc
REVIEW
Must we get it wrong again? A simple intervention to reduce medical error
Q2
Sophie Vaughan, Tristan Bate, Jonathan Round*
St. George’s Hospital NHS Trust, United Kingdom
s u m m a r y
Keywords:
Error
Decision
Workshop
Education
Bias
Q1
Despite medical error being common and important, healthcare workers understanding of the underlying causes is poor. Error recognition and avoidance is rarely taught on training courses, and systems
designed to investigate or prevent errors in healthcare settings are still developing. Instead of using error
avoidance strategies that were reactive, system focused or academic, we developed an approach to help
practitioners identify when decisions are made during clinical situations, and understand what errors
could potentially be made at each. There are three steps to our approach. First is the identification and
classification of medical errors. Ten basic errors are described which participants then identify within
clinical video or written case scenarios. Next, working in groups and using pre-written scenarios,
participants identify switch points e the moments in a case where key decisions are made e and discuss
the reasons behind each choice. Lastly, still working in groups, participants identify switch points in
difficult cases from their own clinical experience and discuss choices made. This step also rehearses an
open, non-judgemental approach to error. This approach can then be transposed into individual practice
and be used in ward rounds, clinic, theatre, and any situation where clinical decision making occurs. If
incorporated by a department it has the potential to dramatically alter the quality of clinical decisions
and reduce the damaging effect of medical error.
Ó 2011 Elsevier Ltd. All rights reserved.
1. Introduction
The devastating consequences and cost of medical errors has led
to increasing demands for clinicians to better understand their
causes.1 Medical error has been classified into a large number of
biases and faults, and approaches for error prevention are
commonly based on these. Errors may also be classified into either
‘person’ or ‘system’ errors with very different error management
strategies for each.2 System errors occur when adequate safeguards
are not put in place to avoid predictable human error. Best known is
Reason’s “Swiss Cheese” model for system safety in describing this
approach.2
One approach acknowledges that humans will always make
errors and therefore safety depends on creating a system to either
make them impossible (an air hose cannot be put into an oxygen
socket) or anticipate these errors with multiple checks or barriers
to avoid them causing harm (two nurses checking the preparation
of a drug).
* Corresponding author. St George’s, University of London, Department of
Paediatric Intensive Care, Cranmer Terrace, Tooting, London SW17 0RE, United
Kingdom.
E-mail address: [email protected] (J. Round).
There have been several high profile system errors, for example
the intrathecal administration of vincristine or wrong site surgery.3
However effective learning from and the elimination of these errors
has been slow to achieve.4
Other strategies for reducing clinical errors focus on ‘person
errors’, highlighting the importance of cognitive factors, especially
those associated with failures in perception, in heuristics and in
biases.5 The use of a metacognitive, reflective approach to problem
solving allows clinicians to step back from the immediate problem
and reflect on the thinking process, in addition to other cognitive
debiasing strategies.6 The large number and range of cognitive
errors described however makes them difficult to teach, recall or
use in clinical practice.
Despite being a major cause of morbidity and mortality, there is
comparatively little time devoted to medical error avoidance in
undergraduate or postgraduate curricula.7 Most published strategies have concentrated on curriculum development for undergraduates, including lectures, video based teaching and
standardised patients.8e11 Perhaps more for medical error than
other topics, a longitudinal approach is needed, introducing key
concepts to undergraduates and then integrating them into
personal practice after graduation.
We devised a simple intervention designed to reduce medical
errors. Its ease of use allows a facilitator with no specific training to
run a session.
2210-8440/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.tacc.2012.01.007
Please cite this article in press as: Vaughan S, et al., Must we get it wrong again? A simple intervention to reduce medical error, Trends in
Anaesthesia and Critical Care (2012), doi:10.1016/j.tacc.2012.01.007
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It simplifies recognition of errors, enables participants to critically review their own cases and see when errors might occur
during their work.
2. Teaching medical error avoidance
We run sessions either as a workshop or as a series of standalone short meetings. For each, the setting is important. Participants need to be able to freely speak and listen to each other,
without interruption and without concern that their comments
may be logged or used outside of the session.
Ground rules (Box 1) are set out at the beginning for clarity of
purpose and so all can understand the format.
The facilitator outlines these first before embarking on a three
step process (Fig. 1). Steps one and two are more theoretical, while
step three relates to individual patients.
3. Identifying and understanding errors e the deadly ten
3.1. Understanding the errors
To simplify understanding and remember causes of error,
participants are introduced to ‘The deadly ten’ (Box 2). In a workshop, this can be done with a short talk. Briefly, these errors are
described below.
3.1.1. Sloth
This is defined as not doing what you should be doing because of
the effort required or (perceived) inadequate reward. It includes not
checking results, not asking for adequate information, not reviewing a patient. It leads to poor documentation and inadequate
attention to detail. Often system errors such as poor staffing or
onerous rotas may augment individual sloth.
3.1.2. Fixation
This error occurs when a particular diagnosis or analysis is
firmly held onto, despite evidence against it. ‘Anchoring’ is
a cognitive bias where features in the initial presentation are
overvalued above subsequent information.6 Similarly ‘Confirmation
bias’ describes a preference for evidence supporting our beliefs over
that opposing them. These short cut biases may save time and
effort12 but lead to decisions being taken before all the available
evidence is considered.
3.1.3. Communication breakdown
Often, within a team, there is sufficient information to manage
the patient successfully. However if this information is not released
or does not reach its destination at the right time, there is
communication breakdown. So unclear instructions, poor listening
and not considering other opinions leads to poor communication
and increases risk of error.
Fig. 1. The three step process.
3.1.4. Poor team working
Good team working prevents errors, allowing each team
member to operate within their abilities, with sufficient time to
discharge their duties. By contrast, if a team attempts to work with
some members out of their depth and others underutilised, or with
some having too much to do, then the team will be ineffective and
inefficient. The team leader will need to be aware of team skills and
the tasks required, to delegate tasks and monitor the function of the
team. Lessons learnt from the aviation industry and motor racing
have helped develop an engineering systems approach to health
care13 with training improving patient safety-related behaviour in
hospitals.14,15
3.1.5. Playing the odds
Clinicians typically favour benign diagnoses over more serious
ones, perhaps because they would not wish a more serious problem
on their patient. They also tend to discount rare disorders, even
when clinical features suggest that the rare disorder is present.
Failing to understand or remember the fundamental rules of
probability can also cause significant errors.6
3.1.6. Bravado
Bravado leads to error when clinicians work beyond their
competence or without adequate supervision. By contrast Timidity
is an error where a clinician fails to take on a task they are trained
for and positioned to do. Bravado is more common in groups where
there is a strong hierarchical structure and little questioning.16
3.1.7. Ignorance
Simply a lack of knowledge, it also comprises Unconscious
Incompetence, where one is not aware of the ignorance.17,18
Ignorance may not only affect our actual knowledge, but also our
consideration of factors which may affect our judgement, such as
fatigue or stress.
Box 2. The deadly ten errors.
Box 1. Ground rules.
Acknowledge that
We are all prone to medical error
Understanding error helps prevent future errors
Medical error is everyone’s responsibility
Comments and opinions should remain confidential
unless patient safety would be at risk
Be honest about what you did or would do
Listen to others to understand their viewpoints
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Sloth
Fixation
Communication breakdown
Poor team working
Playing the odds
Bravado
Ignorance
Mis-triage
Lack of skill
System error
Please cite this article in press as: Vaughan S, et al., Must we get it wrong again? A simple intervention to reduce medical error, Trends in
Anaesthesia and Critical Care (2012), doi:10.1016/j.tacc.2012.01.007
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3.1.8. Mis-triage
Real world medical systems typically involve multiple issues
that have to be prioritised and reconsidered regularly. Over- or
underestimation of the seriousness of a situation and lack of prioritisation occurs at many levels from a triage nurse in the Emergency Department to allocation of resources. Once wrongly
estimated, it sets the pace and tone of subsequent interventions.
3.1.9. Lack of skill
A lack of skill can reflect lack of teaching or lack of practice, such
as performing an operation only rarely. Simulation and skills
training can offer the opportunity to teach and practice these skills
in a safe environment.19
3.1.10. System error
Healthcare systems should be designed to minimise the risk of
error, conscious of how humans will always make mistakes if there
are enough choices to be made. A poorly designed system exposes
staff to unnecessary decision making steps, confuses the decision
maker with multiple distractions, allows dangerous choices to be
easily made and lacks checks and safeguards to identify errors.
System error is a complex area, covering environmental,
equipment or organisational failures.4
3.2. Identifying the errors
After an overview of these ten errors, participants learn to
identify the errors in other people’s scenarios. An effective way to
do this in a workshop setting is ‘medical error bingo’. Clinicians are
given bingo cards containing the 10 errors which they then have to
spot while watching short video clips chosen from popular medical
TV dramas. (Fig. 2). An alternative is to use pre-prepared written
scenarios.
4. Switch points e understanding decision making
Once practitioners are able to categorise and understand types
of errors, the next step is to learn about the structure of a clinical
case. Decisions are not made uniformly during cases, but at specific
times, with ‘doing’ sections separating ‘deciding’ periods. We have
termed the deciding times ‘switch points’.
Decisions made at each of these points affect the clinical course,
diagnosis and outcome. The type and timing of switch points will
vary depending on the clinician, their workplace and their speciality, but common ones are shown in Fig. 3.
By identifying switch points and using a metacognitive
approach to stop and analyse the thinking process and examine for
likely cognitive biases, clinicians can detect and understand why
errors can occur.
In a workshop we use pre-written clinical scenarios with poor
outcomes. Scenarios can be obtained from our error website (www.
jround.co.uk/error). The participants are divided into groups of
4e6, each with a flip chart. Groups map out the key steps in the prewritten scenario and identify switch points. (Fig. 4) Participants
then discuss cognitive processes at switch points and explore why
people might make poor choices at these points. The groups come
together to share what they have learnt and to enable the facilitator
to correct any misunderstandings.
Fig. 2. Bingo card for medical error bingo.
way to start is to analyse their own cases retrospectively in a group.
This step makes learning more personal. It also encourages
collective ownership of safety and error, working to reduce the
stigma of making mistakes.
With a facilitator supporting the group, a participant chooses
and presents a case which did not go well, from his or her own
practice. Again using a flip chart, the clinical course is outlined and
switch points are identified. The group discusses the case and is
encouraged to consider different decisions that might have been
made at each switch point. Effort is made to understand the reasons
behind each of these decisions. Where errors were made, the
facilitator invites the group to consider how they could be prevented in future.
At the end of this step, participants should be able to see how,
within a real case, there are just a few key moments in which
decisions are made, and that these choices can have a profound
impact on the outcome. They will also understand more of why
particular decisions are made, the types of errors that occur and
how practice can be improved.
5. Integrating into clinical practice
Having learnt how to identify errors and switch points in
scenarios, the next step is to relate this to individual practice.
Ultimately the aim is for clinicians to be able to do this on their own
as they see their own patients prospectively. However, an effective
Fig. 3. Timing of common switch points.
Please cite this article in press as: Vaughan S, et al., Must we get it wrong again? A simple intervention to reduce medical error, Trends in
Anaesthesia and Critical Care (2012), doi:10.1016/j.tacc.2012.01.007
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Fig. 4. Example of the key steps in a case, taken from a workshop.
Groups then feed back to the workshop and the facilitator draws
key messages that all can take into their own clinical practice.
5.1. Prospective integration
The steps above can all be completed in a series of teaching
sessions or a workshop, focussing on errors that have already
happened. However, the key purpose of these sessions is to avoid
errors occurring prospectively. This teaching strategy is designed to
help practitioners understand how errors can happen, that errors
happen at specific points in clinical work, and that there is a limited
range of errors that can occur. With the knowledge and techniques
learnt in the sessions, clinicians are better equipped to identify
switch points as they are occurring, and are better able to stop and
consider what errors might develop in a specific situation.
The ways in which this approach is integrated into individual
practice depends on the specifics of each person’s workplace and
speciality. It is important that participants consider how they
should to do this. Some examples are shown in Box 3.
6. Discussion
Despite being aware of the dangers inherent in medical
processes, healthcare practitioners continue to make decisions that
cause harm to patients. There is now a substantial and developing
literature on medical error that highlights both the cognitive
reasons behind poor decisions and the defences that healthcare
systems can develop to minimise error. One of the remaining
challenges for medical teachers is to instill protective cognitive
strategies and error awareness into healthcare workers so that
fewer poor decisions are made.20
In this paper we have presented an approach for teaching the
basics of medical error. Either in a workshop or series of seminars,
participants learn how to identify errors in scenarios, and to
recognise them during an ongoing clinical case.
Our approach uses adult learning theory,21 which emphasises
that learners need to see the immediate relevance of the subject,
that they should use their experience as a basis for learning and
that teaching should focus on problem solving rather than content.
Box 3. Integration strategies.
Weekly ‘difficult patient’ case review sessions
Extended handover meeting
Academic ward round
Clinical governance meetings
Simulation sessions
Please cite this article in press as: Vaughan S, et al., Must we get it wrong again? A simple intervention to reduce medical error, Trends in
Anaesthesia and Critical Care (2012), doi:10.1016/j.tacc.2012.01.007
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This makes our workshops more suited to practitioners rather than
students.
A major challenge facing medical team leaders is the integration
of error prevention into regular departmental practice. Many
hospitals use a reactive approach e exhaustively examining errors
that have already occurred to develop ‘systems’ to prevent recurrence. Others put error prevention into a clinical governance box,
where it fails to properly impact day to day practice.
For an area as important as error prevention, a multifaceted,
integrated and continuous approach is needed. Following a workshop introduction, weekly meetings can be arranged. These would
look at difficult cases in a non-judgemental way, examining the
cognitive processes, and extrapolating ‘take home messages’.
This approach can be integrated into individual decision making
and be used on rounds, in clinic, in theatre, and wherever decision
making occurs. Once incorporated by a department it can
dramatically improve the quality of clinical decisions and reduce
the devastating effect of medical error.
Conflict of interest statement
None.
Acknowledgements
The authors would like to thank the trainees at St. George’s
Hospital for their contribution to the development of the Error
Workshops and Jane Round for her valuable comments on this
article.
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Anaesthesia and Critical Care (2012), doi:10.1016/j.tacc.2012.01.007
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