Error Management Strategies
Professor Lucian Leape, a leading expert on error, has long argued that other industries would not countenance the error rates that are daily found in medicine. His views have been progressively amplified by others. In other high-risk industries it is accepted that error is ubiquitous and (that) it is mandatory to have error management strategies in place to reduce the effects of those errors. Industrial models, taking advantage of controlled conditions, have gone further and demonstrated the benefits of EMS, including that of improved production.
General Electric 'Six Sigman'
For example the latest strategy from General Electric ‘Six Sigma’ achieves such high product reliability that the chance of a defect is six standard deviations away from being a matter of chance i.e. almost one in a million. Studies of disasters such as Three Mile Island, The Herald of Free Enterprise, and Bhopal have illustrated human factors issues similar to those found in medical practice.
We all Make Errors
We know that all humans make frequent errors and they make errors in predictable and patterned ways. Novices make errors due to incomplete knowledge and experts make errors due to the intrinsic hazards of semi-automated behaviour. When humans work in complex systems, and no system is more complex than the National Health Service, the opportunities for error inducing conditions are unlimited and may be exaggerated by cultural and systems deficiencies.
We have documented many examples of these error-inducing conditions during our own research working in operating theatres. The danger is that eventually the consequences of some of these familiar and generally tolerated conditions may well be fatal. In addition, implementing standardized protocols to reduce the potential for human error also enhances staff morale and improves the atmosphere of the workplace
Skills in Leadership and Team-working
There is much to learn from examples in other high risk, safety critical industries. Medicine is probably more complex than any other field of human endeavour, and patients are far more complex and idiosyncratic than aircraft, ships or power stations. The critical similarity is that they all rely on teams of professionals working together, and effective communication is vital in environments that are often highly stressful. While it is clear that flight crews and healthcare leaders are very different their work shows some similarities:
They work in highly complex and large organisations
They lead multi disciplinary teams
They operate in potentially stressful situations
They have to encompass new technology
They have to be managed by many professional managers
They are required to perform management roles within their organisations
They have unique responsibilities for the well being of their team and their passengers/patients
They often have and generally need a ‘can-do’ mentality
Decisons from Incomplete Evidence
Medical practice commonly demands the ability to make decisions on the basis of incomplete evidence. Events are constantly surprising particularly as human anatomy is variable and each patient is unique. During the last 25 years in aviation we have learned the ‘hard way’ about effective methods in human factors training and the development of the skills needed to cope with these challenges which opens up an opportunity to speed up the learning process and apply it to medicine.
The essential skills are in two domains: cognitive and social. They are particularly concerned with the interpretation of behaviour and of group dynamics. The skills are most effectively developed through experiential learning particularly when there is also an opportunity for reflection. It is important that human factors sessions are run by those trained and experienced in facilitation techniques.
The Challenge of Changing Culture
Changing culture can be extremely challenging, especially in a complex organisation such as the NHS. In the field of medicine change has rightfully been driven as a result of sound scientific evidence. Even in aviation where research into human factors has been prolific, it remains difficult to get unequivocal evidence to show the advantages in terms of safety and efficiency. However those of us who had careers that straddled the introduction of human factors training have absolutely no doubts about the advantages in terms of safety, efficiency and workplace environment.
Almost two hundred years ago Ignaz Semmelweis, the Hungarian physician realised that ‘childbed fever’ could be drastically reduced if care-givers washed their hands appropriately. Unfortunately he was unable to persuade his colleagues of the importance of introducing such procedures. The reception from the medical community ranged from coldness to downright hostility. He died a broken man and it was only after his death that those like Joseph Lister were able to provide the evidence of the importance of germ theory and antiseptic policy. Perhaps over the next few years we will be able to provide such evidence with regard to human factors.
Medicine has an unique opportunity to lead other medical disciplines in human factors, due to a high level of experience, expertise and research evidence 13 Implementation of human factors will add to this expertise and will depend on the development of valid categories and standards in the curriculum. The benefit of such regulation would be greater protection for patients, and for professionals. A collaborative approach is essential if training and practice are to be developed in the most effective and economic way.
Author: Guy HIrst