Understanding Generation of Errors: Systems Approach

In health care systems, there is still a prevalence of a ‘judicial’ approach to errors. After an incident, people are generally quick to make judgements which often result in blaming the individual most obviously associated with the incident. This approach is a big barrier to understanding the nature of adverse events and how they can be prevented. In this regard, the healthcare industry has much to learn from other industries, such as aviation and nuclear power, which now have significant track records of a robust safety culture.

One central message from the IOM report has been that, in general, the cause of preventable deaths in healthcare systems is not incompetent or careless people, but bad systems. In order to reach this level of understanding, it is important to understand the aetiology of an error in complex organizations such as hospitals (Box 44.1). A safety incident should be seen in an organizational framework of latent failures – the conditions which produce error and violation – and active failures. This concept is captured in James Reason’s model of an organizational accident. It should be emphasized that some active failures (such as simple mistakes, lapse, fall, slip) have only a local context and can be explained by factors related to individual performance and/or the task at hand. However, it is now understood that major incidents evolve over time and involve many factors.

In the generation of an incident, organizational factors are the beginning of the sequence. These create latent failures which result from the negative consequences of management decisions, and organizational strategy and/or planning. The latent failures then permeate through departmental pathways to the workplace (e.g. the operating theatre complex). Here, they create conditions which allow violations and commission of errors. The errors generated in the workplace environment may be prevented by a front-end clinician (near-miss). However, a simple active failure on the part of the clinician at this stage allows the error to produce damaging outcomes. Figure 44.1 illustrates an example: how a medication error can result from a combination of latent failures, conditions contributing to error and violations, and active failure.

In view of this knowledge, in order to facilitate quality and safety culture, it is important that, first, the healthcare organization must accept that in the vast majority of errors/accidents, ‘system’ failure has a major role to play. Second, the organization needs to be ‘open’ about it, and this openness and transparency must reflect in all their policies and procedures. Third, the organization’s response to these accidents must be ‘just’, and non-punitive for the individual involved. Finally, there must be mechanisms and forums so that ‘learning’ can occur at all levels within the organization, and so that systems are continuously improved.

Focus on Safety Behaviour and Non-Technical Skills

In clinical practice, some personal attributes of health care workers naturally render them more safe than others. These attributes are what one might see in a most highly respected member of a department.

There is now growing realization that these attributes along with non-technical skills are essential among staff to raise quality and safety in an organization. The General Medical Council in the UK makes it clear that doctors are expected to have these personal attributes. Detailed analyses of some of the high-profile incidents in anaesthesia have drawn attention towards non-technical skills. These non-technical skills (NTS) are defined as ‘The cognitive, social and personal resource skills that complement technical skills and contribute to safe and efficient task performance. They are not new or mysterious skills but are essentially what the best practitioners do in order to achieve consistently high performance and what the rest of us do on a good day’.

The underlying premise is that:

In view of these facts, and the recent knowledge about human behaviour under stressful conditions, it is important that health care organizations and workers have commitment to education and practice in non-technical skills. In particular, for the operating theatre environment, the following skills are important:

Communication and Teamwork

Some of us are better communicators and better team workers than others. However, it is now well known that, if the skills are delineated, if awareness is raised about them and tools of learning are implemented by the organization, everyone can improve these skills beyond their previous level. The best possible scenario would be when all members of the team know each other, have mutual trust, are able to discuss problems and issues openly, learn from each other and work together for a common goal. Team leaders have special responsibility for ensuring that they have complete trust in the other members of their team. Listening to each other is extremely important to gain trust. In an ideal world, team members would respect and trust each other, know each others’ strengths and weaknesses, have a low threshold for discussion and learning, and would be able to manage and allocate tasks such that the job at hand is accomplished in the most efficient and safe manner with all members of the team deriving great satisfaction from a job well done. In practice, it is difficult to accomplish this ideal. Therefore, organizations must actively explore and implement tools and training programmes which allow employees to enhance their level of communication and team working.

Pre-list briefings are an important component of this process for the whole operating team. They are tools to foster good communication, planning and learning for the whole team.

Debriefings are a complement to the briefing process (Table 44.2). The concept is that the team reviews its performance each day – did it match the plans made at the start of the day? Good practice is reinforced and areas of improvement are discussed constructively. Information from debriefings should be shared with other team members and necessary actions should be completed and fed back to the team.

Situational Awareness

This term implies broader understanding of ‘what is going on’, and how events may unfold. The term conveys more than just paying attention to the task. For example, a junior trainee anaesthetist being supervised by a middle-grade anaesthetist on emergency duty might be about to anaesthetize a patient undergoing straightforward minor emergency surgery, but also formulating a plan in the event that he/she is called to attend a cardiac arrest elsewhere in the hospital, bearing in mind that the consultant is dealing with a complicated case in another theatre and the middle-grade is very new to the environment of the hospital. The core elements of situational awareness include:

Analyses of major critical events, and experiments in simulated conditions, have shown that, under stress, individuals tend to develop ‘task fixation’, and lose an overall perspective of the situation. A typical example of task fixation would be an anaesthetist single-handedly making multiple attempts at intubating a patient’s trachea while overlooking the facts that the patient has been hypoxic for some time, that the assistant brought the difficult airway trolley into the anaesthetic room some time ago and that a very experienced airway expert and an ENT surgeon are working in close vicinity. Often in the aftermath of an adverse incident, one comes across statements such as ‘I had not realized that….’, ‘we had not anticipated that…..’, ‘it just took us all by surprise…..’.