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Human Factors in Patient Safety

Just A Routine Operation from thinkpublic on Vimeo.

A recent comment asked about sleep deprivation and patient safety. Should we trust doctors who have been up more than 24 hours in a row, when we know their decision making might be impaired? The debate on medical student/resident work hours is enough for a whole other post, but today I’m going to talk about patient safety.

The video “Just A Routine Operation” highlights the dangerous realities of patient care. Mistakes happen. The hospital which is traditionally perceived as a place for people to get better is also one of the most dangerous places for a sick person to be. Doctors over-investigate, super-bugs lurk the wards and decisions are made that impact patient lives.

Having recently done some trauma simulation with other medical students – one where we had a team leader, defined roles, a emergency scenario – I believe there is still a long way to go in making our health care safer. We live in an age of technology, one where imaging and cutting edge interventions are everyday occurrences. There is so much focus on the best evidence based medicine, guidelines and protocols to have best outcomes. Yet, we also live at a time when health care is becoming more fragmented than ever, from generalists and specialists to shift changes and  patient handovers. Long gone are the days where one doctor would look after a patient from start to finish. In this interdisciplinary age, every health care profession has a role to play.

To be honest, they don’t teach us a lot about effective communication in our medical training, at least not in the classrooms. We are given some simulations here, some day classes on closed loop communications, and maybe a handout on clear written communication. We might be exposed to some statistics on medical errors, sessions on isolation precautions, maybe even a talk on things like SBAR.

But as a whole, the health care industry has not taken the same steps on quality assurance, human factors and safety as industries such as aviation, engineering, transportation and food.

Seeing this video today reminded me that I’ll have to be vigilant about how I communicate with my colleagues. That learning to work as a team is often more important than book smarts. I hope you can pass this video on to a health care worker, whether it’s a doctor or a nurse or someone involved with patient care, so that they too can make their workplace a safer place for patients.

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  1. medrunner
    medrunner May 26, 2011

    great video. it’s sad to see that kind of stuff happen, and it is an important thing to come to terms with- our own fallibility. i read atul gawande’s book “checklist manifesto” and it goes into a bit of detail about the errors doctors make and how other industries like construction and aviation have come up with ways to break down those same errors and prevent them from happening.
    he uses the pre-flight checklist as a template to help reduce errors and indicated that having a pre-op talk with everybody really helped open up the communication lines and created an atmosphere where people knew who the lead was, but also understood that they could pipe up when something was not quite right.

    great post, great video and i’m sorry that his wife died… that shouldn’t have happened, but it appears that some good/awareness will come out of it…

  2. m
    m May 26, 2011

    Reading this made me think back to IBM’s new computer “Watson” which is rumored to replace doctors in the near future. At first, I was a bit skeptical – how could they allow a cold hard machine take on such a role? But now that I think about it, having a computer like Watson may actually be beneficial to our healthcare as a whole A machine that can search for evidence and diagnose patients with incredible speed and accuracy means that doctors can now finally shift their focus onto the area you just mentioned: communication.

    • medaholic
      medaholic May 26, 2011

      Hmmm, actually I would say computers aren’t that good at diagnosis compared to humans. Humans are reallly good at pattern recognition, and even if you input all the variables (vital signs, lab values, physical findings) into a computer, they are not able to determine if a patient is sick or not sick, what that rash looks like, etc.

      What computers are good for is helping doctors where they are weak. Constantly monitoring lab values and vital signs. No fatigue. Correcting us if we have the wrong meds or wrong doses. They can check drug interactions, and set up reminders.

      @medrunner – checklists are awesome, just got to make sure everything is on that list to begin with 🙂 it’s easy to get stuck in a routine and forget to think outside the box (checklist)

      • Med School Odyssey
        Med School Odyssey May 27, 2011

        Just to point out something about checklists. If you read Gawande’s book, he makes it clear that putting everything on a checklist doesn’t work. In fact, in his view, the more exhaustive the list, the less likely it will be followed and the more likely steps will be skipped.

  3. larva
    larva June 13, 2011

    As a pilot switching to medicine, I’m finding that there are a lot of similarities between the two. (Even more than I had originally thought)
    Fatigue, error management, inter-team communication, and decision making under stress all seem to come up time and time again. I can’t comment much on the feasibility of checklists in medicine, because I have no medical experience yet, but this is something I would very much like to investigate.

    • medaholic
      medaholic June 13, 2011

      Read Atul Gawande’s “The Checklist Manifesto: How to Get Things Right”

  4. larva
    larva June 13, 2011

    Ahh, I just watched the video. What a tragedy.
    That man definitely hits the nail on the head. A culture needs to exist where all members of a team feel confident enough to speak up if a bad situation is developing. So many plane crashes happened because the co-pilot/engineer/ATC was too scared to question the decision of the captain. I try to impress on all my new co-pilots that when the safety of the flight is in question, even if just in their mind, it is their responsibility to say something.

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