Clinician Decision Errors In Work

1. Clinician Decision Errors In Work Dr Ares Leung Deputy Medical Director 9 October 2010

2. Scope Of Coverage • Only errors in bedside/similar work are discussed • System causes, typos and transcriptions, wrong prescription, etc are not covered • What are they • When are they significant • Reasons behind clinician decision errors: a humanistic discussion • Why errors occur with good doctors • When errors occur: damage control and continuation in role of care provider • Prevention of errors • Support available in UH

3. Agenda • What is an error? • Causes of errors • How to handle errors? • Support Available in UH

4. Error (James Reason) Upright (trip or stumble) Current intention (slip or lapse) Appropriate route towards goal (mistake) Righteousness (sin)

5. ‘Big’ Error, Simple Overlooking

6. Classification Of Errors By Outcome Free lessons Exceedances Incidents Accidents • Near misses as learning • Overdoing for sake of safety • Near misses of sufficient severity to warrant reporting &/or internal investigation; • e.g. minor harm done or major harm marginally defended • Significant adversity arising • Medical setting: the most significant, and present focus Outcome determines whether deviation is error, neutral or even good innovation

7. Classification Based On Action Intrusions appearance of unintended actions Repetitions (of actions already performed) Misordering right actions in wrong sequence Wrong objects right actions on wrong objects Mistiming right actions, wrong time Blends unintended merging of 2 action sequences directed to different goals OMISSIONS difficult to explain / defend

8. Error Prevention General Rule = Experience of others = Non-compliance causes problems

9. Model Borrowed From Driving

10. Speeding

11. Illusions Behind Driving Violations • Illusion of Control • Feels powerful and overestimate extent to which one can govern the outcome of risky situation • Illusion of invulnerability • Underestimates the chances that rule breaking will lead to adversity • Illusion of Superiority • I am more skilled than others • Thinking that he has no higher tendency to violate than others

12. Characteristics of Rule Deviants High opinion of own skills over others Individuals relatively experienced and not especially error prone Subjects with history of incidents & accidents Workers less constrained by opinions positive/negative of others about outcomes Young men Therefore DOCTORS

13. Agenda • What is an error? • Causes of errors • How to handle errors? • Support Available in UH

14. Reasons For Clinician Error • Lack of checking mechanisms • Other staffs: many checkers • Nurses: 3 checks, 5 rights • Doctors: • usually one-to-one interaction with client; • no one else to check; • Issue of confidentiality • Clinician Image as final and authoritative • No remedy

15. Doctor: Robin Hood With 1 Arrow A Doctor has Usually Only 1 Chance

16. Liability Related to Clinician Decision • Natural disease process: • Fate, God’s will, ‘mother nature’ • Result of Clinician Intervention / conscious non-intervention • Liability (although usually credit)

17. Orthodox Management

18. Protection from Orthodox Care Every care provider is ‘clean’.

19. Care Not Orthodox

20. Determinants To Outcome of Medical Error • Outcome • Patient Satisfaction and agenda • Damage Control: communication and care when outcomes unfavourable • Adherence to orthodox management or otherwise • General perception from client about trustworthiness • Perceived competence and care • Issue of unmatched expectation about trust - Performance falls short - Expectation driven too high (patient and clinician contributions)

21. Departure From Orthodox Care Knowledge base Deliberate non-compliance Usual track: leaving outcome to probability Procrastination: dragging on

22. Bias Which Take Us over after Deviations Go for similarity: take forms that correspond to salient aspects of the problem configuration Take reference to frequency: take contextually appropriate, high frequency forms Previously reinforced modes of handling Limitation in brain capacity (bounded rationality): conscious workspace being limited in capacity, is liable to spillage / preoccupation, & overload (Laziness) Reluctant rationality: there is strong preference for automatic, parallel processing, even when the conditions demand computationally powerful but effortful serial processing. Irrationality

23. Factors Favouring Non-compliance

24. A. I don’t know!

25. B. Fatigue • Definite factor • Common element • Reduces memory and adherence with orthodox care • Encourages short-cuts • Prevention • Human: work arrangement, training • Computers for info transferal, monitoring and alert: no fatigue

26. C. Stress • Overloading is a potent cause of stress (plus independent effect to by-pass safety measures) • Different people handle stress differently • Calm & cool, alert & responsive; versus emotional, troubled, anxious, frustrated, social defect senses • Personality • Even in same person: time, situational and preparedness difference • Setting: lack of control, new environment, external factors (personal, family & social, etc) • Stress and anxiety • Initial improvement in performance • Then performance falls as stress increases

27. D. Non-compliance To Safety • Usual Co-workers are reluctance against changes: • Non-compliance to policies and safety measures – e.g., computerization, hand-washing, personal clothing • Personality: 2 – 16% of general population exhibit oppositional defiant disorder • Persistent testing of limits, ignoring rules, exhibiting stubbornness or unwillingness to negotiate or compromise (usually borderline & nonpathological) • American Psychiatric Association 2000

28. E. Impact from Awareness • Everyday example: talking over phone while driving / other activity: you may not be aware of roads traveled • Demand: error free process! High vigilance demand: rapid increase in error rate over time Multitasking especially demanding Human brain automatically selects focus point, width and depth in each process while multitasking

29. F. Change in Care Setting • Beginner’s Luck • It does not exist • There is only beginners’ unluck • Change of status: public to private practice • Public system: team support; rapid change to practically solo situation in private medicine – virtual multitasking • Change to a new hospital: • Subtle changes in cooperation, habits, culture, settings • Attention to every detail mandatory • Help from a buddy, however experienced one is

30. G. The Selfish Giant

31. Personal Gain Element • Possible personal agenda • Financial / Convenience / Client factor • Masking by • Confidentiality • Autonomy • Discrepancy in knowledge between client and attendant • Occasion inappropriate requests from clients: formation of a syndicate (issue with third party payment) • Lack of clinical audit

32. Personal Gain Element: Detection Very high ethical / reputational damage if accusation confirmed Practitioners unfriendly to colleagues are not at higher risk of deviations The deviation in intervention reflects the intention (designed by the practitioner), and a tendency exists (therefore use of statistics)

33. H. Pendulum

34. Evolution of Unorthodox Carethe Beginning • The pendulum which gains momentum • Usual initial deviation very small and suited both clinician and client • Positive reinforcement about • Getting away • Apparent advantage to practitioner • Apparent advantage to some clients (cost, convenience)

35. Unorthodox Care Evolution • It worked last time(s) • Initial high chance of favourable outcome • Medical risk: significance of 10% mortality – high risk and yet 90% get away • Private Practice: no one else knew (rank dependence in public sector) • Protection under ‘autonomy’, ‘confidentiality’ • Gradual increase in deviation until significant deviation and high chance of negative outcome

36. Agenda • What is an error? • Causes of errors • How to handle errors? • Support Available in UH

37. Why Does Bad Outcome Occur After Good Care • It is misfortunes which differentiate the best doctors from the good ones • Why does God give me bad outcomes when I am careful already? • Because I know how to manage bad outcomes better than others. • Finances come last: • Doctors are lucky people who are not bound by money • Take care of patients’ wallets as well • Never walk away after errors because of negative financial return

38. When Errors Do OccurInternal Management: Admittance • Admittance to oneself & team • Honesty: telling the truth (to ourselves and others) • Integrity: living that truth • Toughest part in whole process: realizing and admitting fault • At the core of most problems is a truth one does not want to face • A minute of being honest with oneself is worth more than days, months, or years of self-deception (adapted from ‘The One Minute Apology’)

39. Art of Enlisting Team Support • Not just use of words (behaviour, organization of presentation, body language about attitude are important) • Change in pattern of management to prevent similar occurrence, as soon as it is feasible. • Preservation of peer image in honesty and Integrity • Highest attainment: openness • To colleagues (let others learn from our own mistakes) • To clients (adapted from ‘The One Minute Apology’) • Denial / deferral lead to additional damage, negative effect on integrity, and image in peers • The longer one waits to disclose errors to the team, the more his weakness is perceived as wickedness

40. Personal Creditability(Not Affected By Admittance To Errors) Track record Self awareness Respect from peers and clients, trust Base directives on logic and humane care, not creditability, personal fame, titles, positions, mere records Ability to admit failure and apologise

41. Personal Responsibility Versus the System Very common saying: the system is at fault Who operates the system Determinant of proportion of responsibility: personal control to the system Private medicine: a lot of personal control available We doctors are respected and irreplaceable because we shoulder responsibility

42. Use of Continuum in CarePersonal Efforts • Engagement of clients from beginning of care about possibility to alter courses of care • Monitoring of trend far more accurate than spot conclusions • One cannot be wrong when he has not yet committed, • A matter of scale • in application (percentage of cases so managed) - Family care (automatic return with unfavourable outcome) - Specialty Medical care - Hospital/procedural intervention • In a client (influenced by degree of certainty, urgency of intervention; still applicable to every client

43. Reduction in Chance of Dissatisfaction upon Error • Patient Rapport and Trust reduces probability of complaint upon error occurrence • Rapport and Trust a function of perceived competence and care • Perceived competence • grossly reduced at occurrence of error which affects welfare • May not be changed if there is error but no damage • Perceived care: a matter of communication

44. Communication to Reduce Complaint upon Error Continues after error happens Frank disclosure and engagement of patient, family & friends in remedy Frequent and effective attendance Continuation of professionalism and care

45. Apology to Client • Limitation by consequences and collective indemnity organization • Not for outcome, but because it was the right thing to do to apologize after wrong doing • Difficult to balance • Enlist the experienced • Usual gentle diversion to communication

46. Prevention of Medical ErrorsPersonal Efforts • Meticulous adherence to orthodox care • Review of each less favourable situation • What could have been different? • Empathy: in shoes of other party • Admission to self that mistakes are possible • Find and practice changes • Elimination of ‘leads with least resistance’ towards unorthodox care

47. System Prevention of Clinician Error • Quality Assurance activity • Establish an open system to make unfavourable outcome known to a peer group • Mutual help to prevent deviation towards the unacceptable • Frequent and open, continual if possible • System to receive complaints: • Customer Services Dept • Direct feedback from clients • Very painful • Useful • System to evaluate clinician activity before incidents occur • Survey on satisfaction to doctors • Reasonable Guidelines

48. Agenda • What is an error? • Causes of errors • How to handle errors? • Support Available in UH

49. When Something “Bad” Happens • Seek advice • Dr A Leung only 1 phone away • Other experienced seniors • The CHM & MD • Dr Yu KM, Head of O&G • Dr Clara Wu, Head of Emergency Medicine • Many technically superb colleagues available: • Senior Consultants, Dept Heads • MPS contacts: Richard Butler & JSM

50. Thank you