I have been reading Matthew Syed’ fabulous book Black Box Thinking. I think it should be on the reading list of all decision makers but especially, clinicians, medical politicians and most of all Health Secretaries.
It is a fascinating insight into why errors occur, why they are repeated and how we convince ourselves that they have nothing to do with us!
The chapter on cognitive dissonance is especially interesting. It seems we are hard wired to start developing justification for our errors, from the moment they are revealed. We do this in all areas of life but particularly in medicine. Cognitive dissonance increases the higher up the hierarchical scale. It becomes harder and harder to admit errors the higher up the medical tree one climbs.
The same applies to politicians, perhaps particularly to politicians, as little in government is tested with controlled trials. When things go wrong it is easy for a politician to blame the economy, militant workers, rising prices of commodities, anything but their own decision making. It may not even be conscious and usually is not.
Take Jeremy Hunt’ current stance regarding a seven day NHS. He started out by being convinced by several poor quality trials, some more observations than trials, that a large number of people were dying unnecessarily at weekends due to a lack of medical staff.
I imagine, at the outset, his only aim was to reduce this number by as much as possible. He reasoned that it made perfect sense that more people would die, when there were fewer staff available. It was a convincing narrative.
He then made the controversial decision to move to a ‘seven day NHS’ but given current austerity measures, this had to be done on a cost neutral basis, this was made clear.
He presumably reasoned, that if one spread the routine load over seven days, no extra staff would be required. Less would be done on each day but by fewer staff.
This narrative was then looked at more closely by researchers, expert in this field of analysis. When they delved below the narrative, it became clear that the extra deaths corresponded to the fact, that sicker people were admitted at the weekend. There might be a number of reasons for this. Relatively well people were coming in mid-week for minor procedures, only emergencies were coming in over the weekend. There might be a tendency for GPs to advise those, who ought to go in for investigation, to wait until Monday, as little would happen over the weekend. Had these people been very sick, an immediate admission, would instead, be required.
What happened next is fascinating. Instead of saying ‘ok, this is not as clear cut as I believed’ and taking time to rethink the impact of the changes on the rest of the week, cognitive dissonance meant that to make this step, would have impacted his ego enormously. He had very publicly rounded on Junior doctors who were questioning the validity of the plan, calling them militants or accusing them of not understanding the situation or of being inspired by Marxist trade unionists (these unionists being doctors of the BMA incidentally, the same doctors who had not had a strike for over 50 years).
Mr. Syed, in his book, illustrates a number of situations where normal, reasonable people have put the life of a patient or of passengers, at risk because of cognitive dissonance linked with ego.
One example, involving a senior surgeon, illustrates this. A patient developed an acute anaphylactic allergic response under anaesthetic. The anaesthetist, a safety expert, reported that he felt the patient was allergic to the surgeon’s gloves. The surgeon refused to accept this. He declined several times to change to non-latex gloves, something that would have taken but a moment. Eventually, the more junior anaesthetist asked the surgical nurse to ring the Dean and have the surgeon over-ruled. Only then did the surgeon agree. The rest of the operation was performed in angry silence. The patient survived and was later confirmed to have a latex allergy, had the anaesthetist not insisted, the patient would have died. The cause of death, this would have been ascribed to unpredictable allergic reaction, beyond anyone’s control.
The surgeon painted himself into a corner where cognitive dissonance allowed him to reason, that his behavior was not unreasonable. Even when the anaesthetist pointed out that ‘if I am right and you do not change the gloves, the patient will die. If I am wrong, you spend five minutes changing gloves’. Hierarchical structures such as medicine lend themselves to this sort of situation developing. We need to be made aware of this in order that junior staff have the confidence to question decisions where they see errors being committed or likely to be committed.
The airline industry has taken this on head-on. After all, errors result in the loss not only of passengers but also the crew. Everyone has a vested interest in possible errors being reported and alternative methods being found to avoid these. A culture of reporting and non-blame was developed. Something medicine and government can learn from. I wonder how much the recent trial of two GPs, for negligence over the death of a child from a very rare condition has set this process back. Both were acquitted, but not before every doctor in the land was reminded that to report an error could lead to them being sued in court. Only by not apportioning blame, but instead encouraging error reporting so we can all learn from mistakes in a very complex field.
Why write about this? No doctor has had an error free career. When errors occur they can be fatal. Patterns develop where certain errors are repeated. Take the injection of chemotherapy into the cerebrospinal fluid of people with lymphoma, to kill any residual lymphoma cells in the spine and brain. This used to be done at the same time that Vincristine was to be administered via a vein. I did this many times as a junior doctor after carefully inserting a needle into the spinal fluid. Nothing ever went wrong, I was very careful to ensure the correct drug went in the correct cannula. I may have been lucky I had slept the night before, that no one interrupted my train of thought with an urgent request to go to another ward or to sign an urgent drug sheet. However, Vincristine injected into the spine is fatal! Terrible tragedies happened over many years when young people died because the wrong drug was picked up off the trolley. Eventually the problem was resolved by providing a different bore syringe that would not fit the spinal cannula and by giving the two drugs on separate occasions. This was done after several young doctors had made the fatal error and ruined both their lives and those of a patient and their family. None would have done this negligently on purpose, all would have been, tired, distracted or just under trained or supervised.
So a simple solution to a problem that could not go unnoticed. However, many errors do go unnoticed, because they do not have such severe outcomes or the patient was expected to die anyway. It is only when the error is repeated, where a dangerous drug is being used, that it comes to light. An example would be a doctor prescribing methotrexate daily instead of once weekly, something which leads to bone marrow failure and death if not detected. So an atmosphere of openness and an absence of blame is crucial to progress in reducing errors.
Recent Comments