ETHICAL REFLECTIONS ON ERROR: in defense of a new approach

1. ETHICAL REFLECTIONS ON ERROR: in defense of a new approach N. Yasemin YALIM, MD. PhD Professor of Bioethics Ankara University School of Medicine

2. AGENDA • Malpractice • Errors in general • Seven myths about error • The benign face of the human factor • Real world decision making • Different approaches to error Prof. Dr. Neyyire Yasemin YALIM

3. MALPRACTICE is defined as a professionals lack of knowledge, lack of experience, or negligence that causes harm or leads to a mistake. Prof. Dr. Neyyire Yasemin YALIM

4. ERROR is a failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Prof. Dr. Neyyire Yasemin YALIM

5. ERRORS Failure of conforming a planned action standard for the situation • Lack of necessary skills • Lack of knowledge • Negligence • Psychological factors about the performer • Significant uncertainty • Lack of on-site safety regulations • Lack of standards Prof. Dr. Neyyire Yasemin YALIM

6. HOW HAZARDOUS?! Dangerous Regulated Ultra-safe Health Care Driving Scheduled Mountain Chartered Airlines Climbing Flights European Railroads Bungee Jumping Chemical Manufacturing Nuclear Power 100,000 (>1/1000) (>1/100K) 10,000 1,000 Total lives lost per year 100 10 1 1 10 100 1,000 10,000 100,000 1,000,000 10,000,000 Number of encounters for each fatality Prof. Dr. Neyyire Yasemin YALIM

7. Organizations, Institutions, Policies, Procedures Resources & Constraints Practitioner Monitored Process BLUNT END SHARP END Expertise Errors Results Actions Practitioners work at the sharp-end of the system. The blunt end of the system generates resources, constraints and conflicts that shape the world of technical work and produce latent failures. Prof. Dr. Neyyire Yasemin YALIM

8. SEVEN ERROR MYTHS • Errors are intrinsically bad • Bad people make bad errors • Errors are random and variable • Practice makes perfect • Errors of professionals are rare • But they are sufficient to cause harm • Easier to change people than situations Prof. Dr. Neyyire Yasemin YALIM

9. ABOUT MYTHS • All myths contain a grain of truths. • But the myths to be discussed here arise largely form the emotional baggage that people carry around in their everyday lives. • They present serious impediments to effective error management. Prof. Dr. Neyyire Yasemin YALIM

10. ERRORS ARE INTRINSICALLY BAD • They are essential for coping with novel situations: trial-and-error learning • They are the debit side of a mental ‘balance sheet’ that stands very much in credit: but each ‘asset’ carries a penalty. Prof. Dr. Neyyire Yasemin YALIM

11. UNDER-SPECIFICATION • Errors arise when mental processes necessary for correct performance are under-specified. • Under-specification takes many forms : inattention, incomplete knowledge, sparse sensory data, forgetting, etc. • When processes are under-specified, the mind ‘defaults’ to a response that is frequent, familiar and appropriate for the context. This is very adaptive. Prof. Dr. Neyyire Yasemin YALIM

12. BAD ERRORS, BAD PEOPLE • Often it is the best people that make the worst errors. • About %90 of errors are culpable. • But some people knowingly adopt behaviors more likely to produce error: substance abuse, excessively long working hours. Prof. Dr. Neyyire Yasemin YALIM

13. ERRORS ARE NEITHER RANDOM NOR PARTICULARLY VARIABLE Errors happen when… • You know what you are doing, but the action don’t go as planned (slips, lapses, fumbles) • You think you know what you are doing, but fail to notice contra-indications, apply a bad ‘rule’ or fail to apply a good ‘rule’ (rule-based mistakes and/or violations) • You are not really sure what you are doing (knowledge-based mistakes in novel situations) Prof. Dr. Neyyire Yasemin YALIM

14. PRACTICE MAKES PERFECT • Practice does not make perfect, but it alters the type of error. • Knowledge based errors decrease due to the increasing level of proficiency, while skill based errors increase. Prof. Dr. Neyyire Yasemin YALIM

15. THREE PERFORMANCE LEVELS Prof. Dr. Neyyire Yasemin YALIM

16. PRACTICE ALTERS THE ERROR TYPE Skill-based Knowledge-based Rule-based Prof. Dr. Neyyire Yasemin YALIM

17. ERRORS OF PROFESSIONALS ARE RARE, BUT THEY ARE SUFFICIENT TO CAUSE HARM • Errors are rare but sufficient to cause accidents. Assumption: well-trained operators with good procedures should not make errors. • Errors are commonplace and only very occasionally necessary to complete an accident sequence that usually has a long history. Prof. Dr. Neyyire Yasemin YALIM

18. LATENT FAILURES TRIGGERS Complex systems fail because of the combination of multiple small failures, each individually insufficient to cause an accident. These failures are latent in the system and their pattern changes over time. “Normal” operations NEAR MİSSES ACCIDENT DEFENSES Prof. Dr. Neyyire Yasemin YALIM

19. EASIER TO CHANGE PEOPLE THAN SITUATIONS Two ways of looking at the humancontribution • The PERSON approach: Focuses on the errors and violations of individuals. Remedial efforts directed at people at ‘sharp end’. • The SYSTEM approach: Traces the causal factors back into the system as a whole. Remedial efforts directed at situations and organisations. Prof. Dr. Neyyire Yasemin YALIM

20. MANAGING THE MANAGEABLE • Fallibility is part of the human condition. • We are not going to change the human condition. • But we can change the conditions under which people work. Prof. Dr. Neyyire Yasemin YALIM

21. HUMAN VARIABILITY Human as Human as hazard hero - Slips - Adjustment - Lapses - Compensations - Mistakes - Recoveries - Violations - Improvisations Prof. Dr. Neyyire Yasemin YALIM

22. THE VARIABILITY PARADOX • Errors are implicated in some % 70-80 of accidents. • Elimination of human error is seen as a primary goal by many system managers. • As with technical unreliability, the strive for greater consistency of human action. • But human variability protects the system in a dynamic uncertain world. Prof. Dr. Neyyire Yasemin YALIM

23. REAL WORLD DECISION - MAKING Put your head in the data stream Monitor progress of action Look out a familiar pattern Generate a possible solution Prof. Dr. Neyyire Yasemin YALIM

24. FEATURES OF REAL WORLD DECISION - MAKING TASKS IN ENGINEERING • Ill-structured problems • Uncertain dynamic environments • Shifting, ill-defined or competing goals • Time stress • High stakes • Multiple players • Organizational goals and norms Prof. Dr. Neyyire Yasemin YALIM

25. CLASSICAL (LABORATORY) DECISION - MAKING MODEL A I’ll go for option B Prof. Dr. Neyyire Yasemin YALIM

26. Hindsight Bias After the accident Before the Accident Post-accident reviews identify human error as the ‘cause’ of failure because of hindsight bias. Outcome knowledge makes the path to failure seem to have been foreseeable – although it was not foreseen. Prof. Dr. Neyyire Yasemin YALIM

27. PENALTIES OF BLAMING INDIVIDUALS • Failure to discover latent conditions • Failure to identify error traps • Psychological precursors of error (inattention, forgetfulness, etc.) are the last least manageable contributors • A blame culture and a reporting culture cannot co-exist Prof. Dr. Neyyire Yasemin YALIM

28. A SELF-PERPETUATING CYCLE Blame Pursuit of ‘excellence’ Denial Prof. Dr. Neyyire Yasemin YALIM

29. AN EXAMPLE FOR THE DIFFERENCESBETWEEN A BLAME CULTURE AND A REPORT CULTURE New orderly thought that it is the chloride gallon. Dr. Wrong-Doer pull some chloride from the bottle and injected it to Mr. Unlucky. Cyanide gallon in front of the shelf and its label is semi-readable because of a leak from the ceiling. Like this “C.a.ide” Nurse All-at-Once was fixing the leaking oxygen mask when the orderly came back with the bottle. She pointed at the chloride bottle, so he pour the chemical in it and left. Prof. Dr. Neyyire Yasemin YALIM

30. It is not the end of the story … Create precautions: Like special notices saying that “Are you sure it is safe?” You can still do something!!!!!????? Prof. Dr. Neyyire Yasemin YALIM

31. NEW PRECAUTIONS CAN BE DAMAGED … Prof. Dr. Neyyire Yasemin YALIM

32. WHO IS S(HE) ??? • Long working periods understress factors. • Inadequate resting periods • Continuous heavy workingload • Accumulation of minor events. Prof. Dr. Neyyire Yasemin YALIM

33. The PERSON Approach - A • Operation room staff found out that they mixed the chemicals. • They decided to cover up the situation because all found themselves guilty. • They informed the family that Mr. Unlucky could not make it this time. • No one realized the situation. • They rewrote the tags and had the ceiling repaired next week. Prof. Dr. Neyyire Yasemin YALIM

34. The PERSON Approach - B • Hospital Committee for Malpractice questioned Dr. Wrong-Doer for injecting cyanide to the patient. • They concluded that any careful physician would smell the odor special to cyanide when he/she opened the bottle. • The doctor found guilty for being negligent • He was expelled from the hospital. • The hospital and the malpractice insurance of the physician paid a couple of million dollars to the family. Prof. Dr. Neyyire Yasemin YALIM

35. The PERSON Approach – B • Nurse blamed the orderly for his negligence, but as he never showed up at work again. • The leak on the ceiling was repaired after a number of near misses and two serious accidents. Prof. Dr. Neyyire Yasemin YALIM

36. The SYSTEM Approach • The Hospital Patient Safety and Medical Error Committee learned the situation when Nurse All-at-Once reported the event to them. • The safety team at the operation room traced the evidences and found out the sequence of events that caused the accident. • The Hospital Management gave an apology to the family, they went on an agreement for compensation and both the hospital and the physician’s insurance paid the compensation. Prof. Dr. Neyyire Yasemin YALIM

37. The SYSTEM Approach • The leak was repaired, the tags were renewed. • The safety inspector decided to add an inert colorful chemical to the poisonous chemicals; they divided storages for daily used chemicals and rarely used chemicals etc. Prof. Dr. Neyyire Yasemin YALIM

38. INAPPROPRIATE REACTIONS TOWARDS MALPRACTICE • Organizational reactions to failure focus on human error. • The reactions to failure are; • blame and train • sanctions • new regulations and rules • technology Result is increased complexity and newforms of failure. Prof. Dr. Neyyire Yasemin YALIM

39. SOME PHILOSOPHICAL UNDERPINNINGS • The aim is to reduce harm not errors. • Cooperation across professional roles are essential. • Use prevention – identification – mitigation as principles. • Individual providers, managers, and executives have an obligation to continually work to make the system safer in return for a blame free working environment. • Progress on safety will require a synergy between methods of reliability and safety with professional knowledge and practice. Prof. Dr. Neyyire Yasemin YALIM

40. Every system is perfectly designed to achieve exactly the result it gets. Prof. Dr. Neyyire Yasemin YALIM

41. Prof. Dr. Neyyire Yasemin YALIM