#TPSER9 Reflections: Day Three

By Mary Blackwell, Nursing Student, UPenn

By the end of day three my mind is saturated and I feel so lucky to have the opportunity to be here at the Telluride East Conference. Aside from the twins in utero, as a rising senior in UPenn’s undergraduate nursing program I am certainly the youngest conference attendee. As a student, and a nursing student at that, in the hospital I often feel like the lowest on the food chain. But in this environment of open communication the medical hierarchy collapses and it amazes me to see various healthcare professionals come together for the betterment of patient outcomes. Never before have I had personal connections or meaningful conversations with interdisciplinary healthcare students surrounding issues in healthcare. Because it is so clearly valuable to have these types of conversations, I wonder why academic programs don’t put a larger effort into connecting various healthcare students during their training. Having positive experiences with one another while we’re all still humbled by the title of student could change the culture of staff dynamics in our future clinical settings.

Over the course of the past two days we have heard several stories of near miss or sentinel events in hospitals across the country. As individuals focused on honing our clinical knowledge and skill, it is inevitable to put ourselves in the shoes of the providers in these cases. I shared the shame that several students expressed during these presentations. It was difficult to watch mistake after critical mistake during the tears to transparency videos. It made me cringe in frustration and anticipation as I watched medical professionals continue cause harm to trusting patients. It’s hard to imagine missing the telling vitals signs in the story of Lewis Blackman or passively allowing the sedated Michael Skolnik to sign a consent form. However the focus of our discussions have been that many of these errors arise from faulty systems, not faulty health professionals.

During Terry Fairbank’s discussion of human factors engineering I was able to understand how systems can keep professionals from practicing to their full potential. One of the great examples of systematic hazard was the nurse who accidentally hit the wrong button on the defibrillator in an emergency situation. Instead of delivering the necessary shock to the patient in cardiac arrest, the defibrillator turned off. This delay the life saving care for the patient decreased the patient’s chance of survival. I could imagine myself making this mistake as easily as I do when quickly pressing the wrong button on my cell phone or car. A normal error such as this could happen to anyone in a high stress environment. The instrument was poorly designed; the off button was green while the correct button in this situation was red and flashing. In our society, green means go and red flashing means stop so this design is counter-intuitive.

For the first time I appreciated my constant second-guessing as a student. It’s when patient care becomes routine, second nature that mistakes are easier to make without systematic support. It’s going to be great for us to all go back to our institutions hyper-aware of these systematic barriers.

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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…

Standards for Medical Technology by Fiona Campbell

We had a fantastic talk today by Dr. Terry Fairbanks on the role of Human Factors Engineering in healthcare. It was a very insightful presentation that sparked more questions than answers. Why do we insist, time and again, that people conform to technology and existing systems rather than designing with human limitations in mind? Why do we implement rules based on how work is supposed to be done rather than how work is being done, when we are all aware of the gap between the two? Why do we expect health professionals to achieve perfection when we accept errors from most other people?

It’s frustrating to see how far behind healthcare is compared to most other industries. We are slow to change and slow to adopt technology. It’s even more frustrating to see technology that we have adopted that looks like it was designed by a 10-year-old. As Dr. Fairbanks pointed out, we uphold healthcare products to a different standard than consumer products. When it comes to quality of materials and processing (eg sterility), healthcare products are often held to a higher standard, as they should be (and as is reflected in their price). But when it comes to intuitive user interface and logical design, this standard is often much, much lower. How can it be that virtually every website has a more intuitive user interface than the electronic medical records I’ve tried to use? Or children’s toys that seem to have more logic in their button design than the defibrillators used in situations when every minute matters? Is it because health professionals are supposed to be smart, educated people and therefore are up for the challenge of using more complicated technology than the average person? Perhaps those designing the technology don’t consult with or bother to try to understand their users? Well no matter how smart and educated I become, I think I would take a defibrillator that looks like it’s from Toys-R-Us over one that has the ability to turn itself off, costing 2-3 minutes and possibly a life, just because I pushed the wrong button in a moment of panic.

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