Unraveling Diagnostic Error: Delving Deeply to Identify Hidden Human Factors
On the day the patient had her initial chest x-ray, Radiologist B was late for a meeting with his wife and their respective attorneys to discuss separation and divorce proceedings, and he was fearful of losing custody of his three young children. He was emotionally distracted, rushed, and relying heavily on clinical heuristic skills, thus missing the x-ray finding. Psychosocial impairment, medication and alcohol abuse, and lack of collegial and supervisory support all combined to physically and emotionally degrade Radiologist B, causing him to make a terrible error. The investigation concluded that other radiologists with similar training and experience, if confronted with similar distractions, might also have erred in interpretation of the initial x-ray.
Radiologist B was most definitely responsible and thus accountable for his misinterpretation, which certainly contributed to the timing of this patient’s death and may even have caused it. The hidden human factors contributing to his performance do not remove the responsibility and accountability from his shoulders, but they do showcase how challenging and distracting those factors can be. Opportunities for learning and improvements were thus identified.
Conclusion
Everything about healthcare is complex, and if some in our industry look for simple solutions to complex problems, they, and we, will surely miss important learning opportunities—and patients will continue to suffer.
The variability in quality of root cause analyses must be systematically addressed with the focus on delving deeper to find the rootlets—the contributing factors that ultimately nurture the roots of causality, affect individual performance, and represent the real opportunities for improvements.
Healthcare leaders must understand that there are no shortcuts or heuristics to improve patient safety. Leaders must create and sustain cultures that foster cooperative and collaborative efforts toward diagnosis, and that value the importance of incident reporting and analysis. Only by engaging with clinicians and patients, both key healthcare stakeholders, can we hope to truly mitigate errors. Leaders, and their followers, must embrace transformation of the ways that healthcare can and must be provided (Leape et al., 2009; Cohen, 2014).
Daniel L. Cohen is chief medical officer at Datix, Inc.
REFERENCES
Balogh, E. P., Miller, B. T., & Ball, J. R. (Eds.). (2015). Improving diagnosis in health care. Washington, D.C.: National Academies Press.
Cohen, D. (2014, September 23). Transforming healthcare to avoid harm [Blog post]. Retrieved from www.datixblog.com/category/transforming-healthcare-to-avoid-harm/
Donabedian, A. (2005). Evaluating the quality of medical care. Milbank Q, 83(4), 691–729.
Duchscherer, C., & Davies, J. M. (2012). Systemic, systematic analysis: A practical approach to patient safety reviews. Calgary: Health Quality Council of Alberta.
Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (1999). To err is human: Building a safer health system. Washington, D.C.: National Academies Press.
Leape, L., Berwick, D., Clancy, C., Conway, J., Gluck, P., Guest, J., … Lucian Leape Institute at the National Patient Safety Foundation (2009). Transforming healthcare: A safety imperative. Qual Saf Health Care, 18, 424–428. doi:10.1136/qshc.2009.036954
Makary, M. A., & Daniel, M. (2016, May 3). Medical error—the third leading cause of death in the US. BMJ, 353, i2139. doi:10.1136/bmj.i2139
National Patient Safety Foundation (2015). RCA2: Improving root cause analyses and actions. Boston, MA: National Patient Safety Foundation.
Scott, S. D., Hirschinger, L. E., Cox, K. R., McCoig, M., Brandt, J., & Hall, L. W. (2009). The natural history of recovery for the healthcare provider ‘‘second victim’’ after adverse patient events. Qual Saf Health Care, 18, 325–330. doi:10.1136/qshc.2009.032870
Weick, K., & Sutcliffe, K. (2007). Managing the unexpected: Resilient performance in an age of uncertainty. San Francisco, CA: Jossey Bass.