Why is Pushing the Wrong Button So Easy?

By Sarveshwari Singh

On the first day of the Telluride East Summer Camp, Kathy Pischke-Winn and Dr. Joe Halbach organized a game using dominoes.   It really showed how miscommunication in health care can happen so easily and how simple steps can prevent it.

We assembled in groups of three — one person role-played a doctor, another a nurse, and the other an administrator.  The physician sat with his/her back to the nurse and instructed the nurse how to arrange the dominos according to a prescribed pattern.  The nurse couldn’t ask any questions.  Not surprisingly, the nurse didn’t arrange them correctly.

This scenario brought home how communication disconnects among clinicians happens so often in health care, and it underscores why a leading cause of errors is failure in communication.  Also, informal rules can deter students and residents from asking questions, which can lead to a really bad outcome. That’s what happened to Lewis Blackman, as we saw in Tears to Transparency.

Next, the group got a different domino pattern and could have a briefing before the start of the game.  Also, I noticed that in our group, the person playing the physician gave more precise instructions and repeated them for more clarity.  So there was learning and improvement between the first and second rounds. This time, the person role-playing the nurse arranged the dominoes correctly.

I took away from this experience lessons on how I need to be precise in communicating, whether in the classroom, at work or at home.

Being transparent…time for confessions

I found myself feeling upset today, especially as we were discussing the case study. I felt so frustrated as a nurse when we were trying to figure out the accountable person for the patient fall. I felt like I had a weight on my shoulders. As nurses, we do shoulder a large portion of the responsibility related to patient falls. We talked this afternoon about how it is EVERYONE’s responsibility to help WATCH the patients in an effort to prevent falls.

I also confessed to my group that a lot of times I do not feel comfortable going to lunch when I am staffing. Why, you might ask? I know part of it is that it is hard for me to hand over control of my patients to another nurse, even if only for 30 minutes. So, I am working on that. The other part is that I work with a young group of nurses (young in experience), and so sometimes I am nervous about leaving my unit. I know that I need to build better trust. It will be one of my goals.

Trust and Safety in Medicine: Part 2 by Matthew Waitner M2 Georgetown

Perhaps, as Terry Fairbanks said yesterday, we should look not to our individual pursuits but the healthcare system that is in place.  Individually, we are each committed to the reason we put on the white coat – to cure, heal, and do our best to care for each of our patients.  And yet collectively as a system we are failing to provide that very goal.  How is it possible that such dedicated individuals are systemically failing – it would appear to be impossible, and the numbers certainly show that its more than just a few bad apples.  Perhaps our system needs to be overhauled.

I was struck at the insight that Dr. Fairbanks shared.  As a human factor engineer he explained that every other system in the world accounts for the natural errors in humanity.  There are fail-safes embedded in most systems to catch the errors before they cause undue harm.  Such fail-safes are not present in the culture of healthcare.  While every hospital is claiming to be patient-centered, we often fail to see the humanity within ourselves.  I am firmly convinced at this point that a systemic culture change is the only solution to our never-ending problem of patient safety.  Dr. Fairbanks made it clear that skill-based errors (or better put, automated errors) are the key to controlling our out of control safety issues.  In fact, as a first year medical student we learned in our neuroscience course about types of memory: short-term, declarative (semantic and episodic), procedural, priming, associative, and non-associative.  The last of these (non-associative learning) is when someone is habitually exposed to the same event over and over again that the event is done by rote.  This should sound familiar, as it’s the same as skill-based tasks that require automation or limited cognitive input in order to be achieved.

From my class example, this is when you live over a flight path (which I actually do), and you tune out the sound of the overhead planes because you hear them every few minutes.  Every once in a while a plane will fly lower causing a louder that normal event that triggers you to notice them again, and again with habituation it disappears from your thoughts.  So it is clear that our mind can become habituated by automated responses that require little cognition, and it is only when there is a difference that your routine is noted.  Hence is the case discussed today of the NICU heparin incident – habituation caused major medical errors.  I am fascinated by the idea that this system error could have been avoided if there had been a slight difference (a different shaped vial, a different drawer, any change from the expected norm).  Dr. Fairbanks would argue that this is how well-meaning, caring professionals make simple mistakes that cost lives – and it is not the individual practitioner, it is the system involved regardless of how mindful we may be.  That same error was noted in the book “Why hospitals should fly” when the flaps were not engaged yet 3 people confirmed a 15,15 green (indicating the flaps were extended) – it was the expected result and therefore it was what was seen.  These sorts of systemic errors are where the most margin for improvement can occur – because like any job, medicine becomes routine and we become habituated, and our brains are physiologically wired to become habituated.

To say this conference has been insightful would fall short of its true meaning in my eyes as a future medical professional.  These past two days have shown me that our profession is far from perfect (even though each of us strives for such), and requires some major safety overhaul before the public catches wind of our missteps.  In fact, I’m not sure how much longer we can pull the wool over their eyes before they catch us red-handed, and I’m not exactly sure how we have been fooling them for as long as we have.  The numbers are out there, the mistakes make headlines, and yet we are still more trustworthy than a stranger on the street, and we deserve no such pride.  As medical professionals, its time to put egos aside and start doing what we swore an oath to do: do no harm.

Trust and Safety in Medicine: Part One by Matthew Waitner M2

George_WashingtonI have been participating in the Telluride East conference taking place in Washington, DC since August 1. In the whirlwind two days I have been barraged by information, struggled through leadership, boggled by safety concerns, and simply overwhelmed by my own emotions.  To put it bluntly, this is the most interesting two days I have spent all summer, and even though I am exhausted, I am beyond stimulated by the experience of this conference.  One minute we are hearing from Paul Levy on negotiations and the next we are working on teamwork and leadership in a teeter totter game with 9 teammates, a 2×8, a cinder block and 2 eggs.  Suffice to say this is truly a hands on and experiential learning experience like none other.

In reflecting on the past two days I have stumbled upon many thought trains (thanks Cliff), but one that my psyche continues to grapple with is the following conundrum: How can the medical community as a whole commit so many errors as to kill nearly 100,000 patients yearly (for at least 13 years according to the IOM), and still be considered one of the most trustworthy professions in the country?

All I have to say is, whatever PR firm is handling healthcare’s interest deserves some large bonuses for pulling off this feat.  Nurses, Pharmacists, and Doctors all top the list here in the US according to the most recent Gallup poll in November (http://www.gallup.com/poll/1654/honesty-ethics-professions.aspx), nurses rank #4 and physicians #6 in Australia (http://www.readersdigest.com.au/most-trusted-professions-2013) and doctors rank #1 in the UK (http://www.gponline.com/News/article/1171314/Poll-reveals-doctors-trusted-profession/).  Seriously – this PR firm not only succeeded here in the US, but internationally as well.  I am stunned because on average (in the US) we kill 272 people per day due to medical errors which is the equivalent of two Boeing 737 crashing each and every day (total capacity per 737 = 137).

According to today’s presentation by Terry Fairbanks, we have a 1:616 adverse incident rate as a field – akin to bungee jumping in safety, while other professions soar in safety comparatively.  How could we possibly still believe then that healthcare professionals are still worthy of the patient’s trust? My only conclusion is that we as a profession do not deserve such accolades until we get our house in order and focus on patient safety.

What continues to be mind-boggling about this conundrum is that the population polled must have had some interaction at one point or another with the medical field.  Healthcare touches nearly every life in the country either directly or indirectly, and yet we are still given the distinct honor of being one of the most trustworthy professions.  This is even after Press Ganey scores (indicating mediocre treatment in the hospital, as any front-line employee will indicate), after outrageous hospital acquired infection rates (about 1.7 million yearly according to the CDC), and our dismal rate of iatrogenic death previously discussed.  Why are people not more outraged at these numbers?  As a future physician, these numbers are staggering and show that truly patients should not trust our professions.  So, truly, whatever PR firm is handling medicine must be doing one hell of a job and be making a killing in the process.  Seriously though, these numbers and our perception are at complete odds with one another and deserve to be honestly considered.

The only conclusion I have been able to draw from this analysis is that the healthcare profession has been given nearly implicit trust by our patients, by simply putting on a white coat, and we have done a horrible and dismal job of accepting that trust and caring for our patients safely.  Again I ask, where is the outrage?  Are people not doing the math? Where is the expose on 60 minutes or 20/20?  Frankly I’m surprised anyone trusts us at all, and if we are going to continue to receive such trust, we best make some changes fast to ensure that this trust is correctly placed.   From my perspective, somewhere in our profession, we have determined that while patients are the reason we exist, they are not to be treated as having such power.  Instead of being patient centered and safety conscious, we have turned healing into a business focused on doing more and caring less.  I am appalled as a future professional that this has been allowed to occur.  I, as many others reading this blog, came to this profession in order to diagnose, heal, and comfort people in their most dire need.  How could our profession have lost sight of our reasons for entering the profession in the first place?

Stay tuned for Part 2…

Sick or Not Sick? The Healthcare Provider’s Sixth Sense

I wrote the following today on my scrap paper after learning of the story of the tragic death of the young boy, Lewis. The factor that most struck me regarding his death was the failure of the junior team members to recognize that something was wrong over the weekend. It led me to the following reflection:

The scariest part of my surgery rotation as a third year medical student was taking weekend call. It was me, an intern, and a junior resident – usually a PGY 2 covering the entire floor and everyone walking through the ER door. Not one of the three of us had enough clinical experience to have yet developed that sixth sense that helps you tell if someone is “sick” or “not-so-sick.” A good attending physician can look at a patient from across the room and know that something is wrong, but that skill comes with experience, which none of us had. How many people had only subtle signs of illness that we missed and failed to recognize as “sick”? Lewis had subtle signs and probably looked sick, but none of the residents caught what an attending likely would not have missed.

In the end, I think it is great that we now feel more comfortable calling our chief residents and attendings on weekends or in the middle of the night, but in a case like Lewis’s would we have even thought to call? Would we have even recognized that something was wrong? In the ER, you never put your newest nurse on triage, so why on surgery were the most junior team members the ones left triaging what information was relayed to the more senior physicians? Until residents develop the ability to get a good general impression of the patient, no patient should stay in the hospital without an attending examining them.

Telluride Reflections by Quyen Nguyen


One of the most important lessons I have learned from the past three days is the urgency in which we need to act to bring ethics back to the forefront of healthcare systems. Too often the best interests of the patients and their families are put behind financial, legal, and personal factors. It may never be possible to prevent every error, but we have a professional duty to take responsibility and put patients’ and their families’ needs first in the aftermath of a medical error. I wish to express a sincere thank-you to Carole for your courage in sharing your personal story so that future healthcare professionals can learn from it. I hope that each of us will continue this conversation of patient safety to make a difference in patient care when we return to our institutions.

Today I also learned about the concept of anchoring. Anchoring is a practice in which a person’s perspective is biased by the first information given. The tendency of anchoring increases significantly when one becomes tired, fatigued or distracted by any other human factors. The heartbreaking tragedy we have seen in Carole’s and Helen’s stories stems from anchoring bias. As a caregiver, we have to be mindful and avoid bias when dealing with patients. However, after several talks with several medical students and nursing students, I learned that many residents may have to work up to 80 hours/week on average and many times they have to work more than 8 hours in a shift (please correct me if I am wrong). I wonder whether it is possible for one to maintain a clear mind with an objective perspective under these working conditions. Should there be a change to reduce such long working hours in residency programs?

Yesterday, I went shopping and talked to a cashier in a souvenir shop in downtown Telluride. After I asked her whether she offered any discount for Telluride scientists, we started having an interesting conversation. On being asked what I was there for, I shared with her that I was in a 4-day summer school with medical students, nursing students, and pharmacy students to learn more about patient safety and how to improve healthcare quality. She then told me that since we were learning about patient safety, we should make sure that nursing school teaches nurses how to take blood sample of a patient without pricking her patient five or six times. She suggested that doctors should invent some kind of X-ray imaging on a patient’s arm so that they can test the blood without pricking a patient. We both laughed and I said, “Yeah, why not?” Such an invention may be possible in the future and it would increase the ability to deliver high quality patient care. I thought this is an interesting anecdote of those outside the medical profession on how they perceive those inside.

Reflections on Going Home

I have been interested in quality and safety since being personally harmed during a hospitalization many years ago. However, during medical school I’ve had some trouble finding students, faculty, and administrators that share my interest. Here at Telluride, I feel lucky to finally be surrounded by the faculty and colleagues that have such passion for patient safety.
While feeling lucky to attend this conference, I spend most of my reflective time wondering how to bring the education, ideas, and enthusiasm back to my home school to make meaningful change. Too often we attend an excellent meeting and come away with new concepts and empowering memories, but when we return home it is difficult to transform these into concrete change.  I look forward to designing/implementing my project this year and seeing other people do theirs. That way I know that stories like Carole’s or Helen’s will not only have had a personal influence on me, but have actually helped improve the care of the next generation of patients.
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