Unthinkable errors occur in hospitals all the timeƒfrom patients who have the wrong extremity amputated to medication mix-ups thatend in death. In 1999, Lucian Leape, MD,a professor at the Harvard School of Public Health, told a U.S. Congressional subcommittee that one million people are injured by medical errors in hospitals each year and that 120,000 deaths result from those errors. This is three times the number of people who die in motor vehicle crashes (MVCs). The estimated cost? $33 billion annually.
Despite our increased awareness, the rate of medical errors hasn_t decreased over the past 10 years. Leape and others believe this is due to our obsession with assigning blame and punishing those responsible. This punitive environment doesn_t promote a culture in which employees and employers feel encouraged to critically analyze the cause of errors, let alone acknowledge their occurrence. Leape suggested that because of fear of retribution, only 2Ï3% of major errors are reported through existing mechanisms.
So what do we do to change this? Human error analysis isn_t new and isn_t unique to medicine. The aviation industry has been particularly interested in minimizing human error for many years. Unfortunately, the medical profession has been slow to adopt best practices from other disciplines.
Although there are several approaches,I_ve found that "The Just Culture Community" professed by David Marx, JD, is easily adapted to health care. It_s based on the assumption that we all make errors and, as employers or medical directors, we can expect our personnel to err while caring for our patients. How we deal with the error depends on the behavior that caused it. Marx proposes that all errors stem from three specific behaviors, each with their own set of characteristics and managements: human error, at-risk behavior and reckless behavior.
An inadvertent or inappropriate action is often referred to as a "slip" or "lapse." For instance, when we miss an exit on the freeway because the sign was poorly lit, and we have to take the next offramp. We may recognize our mistake soon after it occurs and have time to correct it. But sometimes the error has more far-reaching ramifications.
Let_s take the following example. EMS is called to a nursing home where they find an elderly man in full arrest surrounded by a hysterical family. The crew begins resuscitation and transports the patient to the emergency department. Once there, they learn he was DNR/DNI. Normally, the crew would have asked about code status, but the dynamics of the situation distracted them. Is someone to blame here? No. The system is to blame. There were many opportunities for the system to notify responders that the patient was DNR, from the 9-1-1 call bythe nursing staff to the bracelet that should have been on his wrist.
The Just Culture community manages error through processes, procedures, training and design, such as training on handling DNRs and placing similarly labeled medications in different pouches. But people still make mistakes. And when they happen, the employee should be approached and supported. And it should be explained to them that the error was beyond their control.
At-risk behavior means the potential for risk wasn_t recognized or the behavior was mistakenly believed to be justified. For example, EMS is called to the home of a man with chest pain who meets the crew at the door. He_s clutching his chest and diaphoretic. The ambulance is 30 feet away, and the EMT is just opening the doors. The medic opts to walk the patient to the ambulance instead of lowering him to the floor to assess him. His 12-lead ECG shows an acute myocardial infarction, and his BP is 80/palp. The crew transports him directly to the cath lab without incident.
Although this story has a happy ending, what do you think would have been the outcome of an investigation had the man collapsed and arrested while being walked to the ambulance? We frequently walk patients to the ambulance, and sometimes they refuse to use the cot. The evaluation of the at-risk behavior is generally an assessment of "what ifs." During the debriefing, the crew may claim it shortened their scene time or that the patient "didn_t look that sick." But walking a cardiac patient to the ambulance (causing them to exert themselves) is just not good practice.
The Just Culture approach manages at-risk behavior by removing incentives for such behavior, creating incentives for healthy behaviors and increasing situational awareness, which generally engenders a better understanding of the level of riskthat providers and their agency should be comfortable with. It involves coaching with the expectation of change in behavior.
The last behavior is when we choose to consciously disregard a substantial and unjustifiable risk. For example, EMS responds to an MVC where the police tell them the driver is intoxicated and in their custody and there_s no need for EMS to evaluate them unless they want to. They elect to return to base, and the patient is later found dead in his jail cell from hypoglycemia. Or a crew is intubating a patient and decides not to use any form of tube verification, relying solely on "intuition and experience." The tube is found to be in the esophagus at the ED.
In both cases, there are clear policies covering what should occur. In the first, the service should be required to assess all patients at the scene of an MVC, and in the second, the medical director should require multiple forms of tube verification.
The Just Culture practice manages reckless behavior though remedial and potentially punitive action, and the resolution should follow a progressive discipline procedure. Reckless behavior is a rare event; the vast majority of medical errors are due to human error, but they_re approached as if they are caused by reckless behavior. Investigations quickly turn into interrogations, and instead of solutions, we create more problems.
Just the End
The goal of the Just Culture Community is to create an environment where your EMS personnel will point out potential concerns before they ever result in patient harm. This starts with simple equipment issues and slowly progresses to reporting of errors by others, until you eventually reach the ultimate state of security in which your staff fearlessly reports their own errors. If EMS providers are afraid to admit their errors, they_ll never have the opportunity to learn from their mistakes. To learn more about The Just Culture Community, visitwww.justculture.org.JEMS
Keith Wesley MD, FACEP, is the Minnesota State Medical Director and EMS medical director for HealthEast in St. Paul, Minn. Contact him firstname.lastname@example.org.References
- Institution of Medicine Report: "To Err is Human: Building a Safer Health System." 1999.
- Bleich S: "Medical Errors: Five Years After the IOM Report." The Commonwealth Fund.