Medical Error: System Solutions vs. Blame

“If you guys can’t think to order pregnancy tests, we’ve got big problems!” the consultant said.

He was a heart expert, but he remembered medical school: women of childbearing age with abdominal pain and/or bleeding must have pregnancy tests.

We forget simple things, make simple cognitive errors, all the time.

Intelligence or experience will not protect you.

Every day brilliant people forget to:

close their zippers,
signal lane changes,
turn off the oven,
feed the cat,
lock the door

Medicine overflows with cognitive traps. It brims with safety-critical activity: you get only one chance to do something right or patients will suffer & die.

For example, a missed ectopic pregnancy can cause a woman to bleed to death. An ectopic exists in 6-16% of women with pain and bleeding in the ED. Every medical student learns early that ordering a pregnancy test can save lives.

But very rarely, blood-work gets ordered without a pregnancy test when providers are left to order lab tests separately.

The consultant believed emergency docs must be even more stupid than he suspected. How could they miss something every medical student knows?

Uninformed individuals still blame people; experts tell us to blame the system.

Errors do not happen for lack of knowledge.

We must improve the system and stop the ‘blame and shame’.

System solutions – 2 examples:

Behaviour-shaping constraints, or forcing functions. For example, you cannot get your bank slip from a bank machine without collecting your bank card first; you cannot start your microwave without closing the door first; you can’t start your car without putting it into park. Constraints prevent medical mistakes.

Opt out vs. opt in: these terms get used in advertising and mailing lists. To capture everyone for a list, advertisers put people on the list until they ask to be taken off. Advertisers assume you want to be on the list, opt in is assumed, until you opt out. (Opt out pops up in discussions about ways to increase organ donation)

Using opt out for lab panels for women of childbearing age with abdominal pain could decrease the chance of forgetting a pregnancy test. Providers could opt out of performing the pregnancy test, but would be forced to think about it first.

Some still resist system solutions and try to blame people for medical errors. What do you think? Can we rely on system design to decrease error?

Quality in Healthcare, Patient Wait Times, & MD Arrogance

Physicians believe that:

Anyone who delivers care in less time than me must be cutting corners and providing low quality care. Same goes for clinics, hospitals, emergency departments…

Do physicians believe, then, that taking longer would improve quality? Does more time equal more quality?

Deep down, many physicians believe that:

The highest quality care happens at precisely the speed at which I provide it, or could provide it, if I chose to work at my top speed.

This could just be physicians resisting change for their own reasons. But I think there’s more…

Outcomes & Quality in Healthcare

Patients believe compassion equals quality, and rightly so: quality care must be compassionate.

But patients also want great outcomes.

Time determines outcome for most EM care (ICES Quality Report, 22 of 48 indicators are time based).

Many papers show ways to decrease waste for patients: see articles on LEAN and time in emergency care.

EM associations teach ways to increase speed without decreasing quality (Physician Efficiency, Canadian Journal of Emergency Medicine; Doing Things Faster Without Sacrificing Quality, ACEP), and many report ways to speed up care (Speed it up from Stanford 2013; ERs Move to Speed Care, WSJ 2011).

Time equals quality in emergency care. There is no evidence that patient waiting or taking-a-long-time-to-provide-care equals quality.

Humility can help to improve performance. Are we willing to look for ways to improve based on others’ success?

Physicians Limit Freedom?

A group of doctors discussed gambling.

“You’d never believe the pain some of my patients experience with problem gambling,” one said.

“We should lobby government to stop using revenues from gambling!” said another.

Some listeners nodded.

“Don’t we finance hospitals with lotteries?”

Silence.

“Should physicians dictate morality?” someone asked.

Doctors Limit Freedom?

Regardless of the morality of gambling and casinos, should physicians advocate for laws that limit patient freedom? What is the role of freedom in health and human flourishing?

A physician leader frowned at my defence of patient freedom.

“When do we stop making laws and start supporting individual freedom?” I asked.

“Don’t you agree with seat belts?” he asked. “How about stop signs?”

“Of course I agree with seat belts and stop signs,” I said.

“Well, then you agree with government limiting free choice!”

Now there’s the rub: how much freedom do we give up to live together in a ‘free’ society?

People who conflate stop signs with prohibition confuse mutual limits on individual freedom with imposing personal preference on others.

It’s one thing for us to obey stop signs for the safety of all. It’s something else entirely for intelligentsia to impose restrictions on other people’s behaviour that have little to do with their own freedom.

What do you think? Where do we draw the line between promoting healthy ideas and limiting individual freedom? Who should decide? Do we need more health related laws or do we have too many already?