GETTING PAST BLAME
How Can We Save the Next Victim?
Published: June 15, 1997
(Page 5 of 8)
Now it seems to be medicine's turn, and human factors researchers have been expecting the call. Even before anyone asked for their help, they had spent a lot of time analyzing that industry. From where they sat, health care was the pinnacle of challenges, the most complex of industries, the ultimate test of systems theory.
''Health care is really interesting from our point of view because it straddles the entire span, the spectrum of accidents,'' says James Reason, a psychology professor at the University of Manchester and one of the first human factors researchers.
In other industries, the relationships are between operators and equipment - pilots and their airplanes, nuclear plant personnel and their walls of confusing displays and dials. In medicine, the relationships involve operatings, equipment and patients - patients who, by definition, are not in perfect working order, creating infinitely more ways for things to go wrong.
It was inevitable, human factors experts agree, that medicine would eventually shed its resistance to being seen as a system in which human beings were but one fallible component. That it took a string of tragedies to spur that realization is probably also inevitable. The first step, researchers are telling clinicians, is to accept that perfect human performance is not an attainable goal. People are not perfect outside a hospital. Half asleep, they spray deodorant on their heads and hair spray under their arms. Distracted, they write the wrong dates on checks. On autopilot, they leave their phone numbers when they mean to leave their fax numbers.
They are equally imperfect inside a hospital. They write the cumulative chemotherapy dose instead of the daily dose. They write ''left leg'' when they mean ''right leg.''
Admitting to imperfection is a first step for medicine, because many in the profession seem to believe that they can be perfect, says Robert L. Helmreich, a human factors expert at the University of Texas at Austin who spent years helping airlines teach pilots that they were fallible. ''The think they're bulletproof,'' Helmreich says.
He cites a 1988 survey of pilots in which 42 percent agreed with the statement, ''Even when I am fatigued, I perform effectively.'' He was amazed by that until 1996, when he gave the same survey to surgeons, anesthesiologists and nurses and found that 60 percent agreed with the statement.
The central problem with the belief in perfection is that hospital systems are designed around it. They rely on concentration - that the nurse, for instance, will connect the nutrition bag to the nutrition line and not to the dialysis line. But things should be designed, human factors experts would argue, so that the connective port on the nurtition bag fits only into the connective port on the nurtition line.
Systems based on perfection also deny the possibility of confusion - trusting that a nurse will always double-check whether she is dispensing the right drug and not a similarly packaged or a similarly named one. And they depend on memory - on a resident remembering to write down the correct dose of Digoxin, rather than on a computer system devised so that it won't accept a prescription with an erroneous dose of Digoxin.
The possible remedies for this dependence are many, and they vary with the problems of each hospital, which leads to perhaps the most important message of human factors research. ''You cannot solve your problems,'' says David Woods, a professor of cognitive systems engineering at Ohio State University, ''until you know what they are. And you will now know what they are unless you create an environment where people feel free to tell you.''
Every industry that has substantially reduced error, experts say, has created a blame-free environment for reporting errors. And that includes not only actual errors, but also near misses, which have traditionally been seen as evidence of the strength of the system, but are more likely examples of errors waiting to happen.
For instance, an airline pilot must carry a form as part of the Aviation Safety Reporting System. When he makes or sees a major foulup, Helmreich says, he fills out that form - including his name - and sends it to NASA. The agency has a week to contract the pilot for amplification or clarification. Then the information is put in a computer but without the pilot's name.
Whie the thorough and honest reporting of error is a central message of the experts, it is the trickiest for medicine to hear. Some hospitals are trying: James Conway at Dana-Farber, for one, has sent thank-you notes to staff members who report errors. But this zealous honesty does not come easily to a profession trained to understand that anything written down is discoverable evidence in a malpractice suit; it doesn't help that many states have chosen to confront error by publishing lists of doctors who have been disciplined or sued. In fact, no one is more interested in these latest changes by doctors than malpractice lawyers
''On the surface, it does sound intriguing,'' says Judith A. Livingston, a personal injury lawyer at Kramer, Dillof, Tessel, Duffy & Moore in Manhattan. ''But of course I'm skeptical.'' She does not see health care workers the same way human factors researchers do, and worries that this is merely a way for doctors to avoid blame. Yes, she says, the sysem often fails, but that does not mean that the individuals in that system are not responsible for their contributory actions.