severe events Insufficiently standardized in practice
Delays and errors in clinical decision‐making are particularly critical in medicine, and there is extensive literature about the complexities of medical decision‐making.23 In our daily clinical practice, we use heuristics, which are simple but approximate rules to aid decision‐making by simplifying the situation and decision to be made. Particularly during times of fatigue, stress, or time pressure, these heuristics can become biases, leading to faulty clinical decision‐making and undesirable consequences.24 Some of these, with common clinical examples, are given in Table 11.4.
System and organizational factors
Errors and human behaviour cannot be understood in isolation but only in relation to the context in which people are working. Clinical staff are influenced by the nature of the task they are carrying out, the team they work with, their working environment, and the wider organizational context; these are the system factors. The systems in which we work have inbuilt defences and barriers, and it is only when these defences are simultaneously breached that adverse events occur. This concept forms the basis of Reason’s Swiss cheese model, shown in Figure 11.1.
Table 11.4 Examples of some cognitive biases and heuristics that commonly affect clinical reasoning.
Source: Adapted from Redelmeier24.
| Name | Definition | Example |
|---|---|---|
| Availability heuristic | Making judgements based on cases that spring easily to mind | ‘The last time I saw a patient with fever and a headache, it was only flu, so it is likely to be so in this case too’ (actually meningitis) |
| Anchoring heuristic | Sticking with initial impressions | The confused elderly patient who has a ‘UTI’ on admission (despite a negative MSU), whose severe constipation goes unnoticed |
| Framing effects | Making a decision based on how the information is presented to you | ‘A&E referred this patient with fever and haemoptysis as “pneumonia”, so that is the most likely diagnosis even though the CXR is normal’ (actually a PE) |
| Blind obedience | Showing undue deference to seniority or technology – ‘they must be right, and I must be wrong’! | ‘My consultant said that this patient could go home, so I am going to ignore concerns raised by nursing staff’; ‘The blood results show a normal haemoglobin even though this patient looks clinically anaemic – the blood results must be right’ |
| Premature closure | Being satisfied too easily with an explanation | In a patient with staphylococcal sepsis, assuming the source of sepsis is their cellulitic leg and missing their underlying endocarditis |
Figure 11.1 Reason’s Swiss cheese model.
Learning from high‐reliability organizations in other industries that achieve high levels of safety and performance in the face of considerable hazards and operational complexity is an ongoing challenge to improve safety in healthcare. Important characteristics of these organizations are their safety culture and leadership: there is evidence that these are related to some safety measures in healthcare.
Analyses of incidents usually reveal the causes to be a combination of all the factors described above. This can be summarized by ‘the seven‐level framework’,25 which conceptualizes the patient, task and technology, staff, team, working environment, and organizational and institutional environmental factors that influence clinical practice. This is shown in Table 11.5.
Table 11.5 The seven‐level framework.
Source: Adapted from Vincent, et al.25
| Factor types | Contributory influencing factor |
|---|---|
| Patient factors | Condition (complexity and seriousness) Language and communication Personality and social factors |
| Task and technology factors | Task design and clarity of structure Availability and use of protocols Availability and accuracy of test results Decision‐making aids |
| Individual (staff) factors | Knowledge and skills Competence Physical and mental health |
| Team factors | Verbal communication Written communication Supervision and seeking help Team leadership |
| Work environmental factors | Staffing levels and skills mix Workload and shift patterns Design, availability, and maintenance of equipment Administrative and managerial support Physical environment |
| Organizational and management factors | Financial resources and constraints Organizational structure Policy, standards and goals Safety culture and priorities |
| Institutional context factors | Economic and regulatory context National health service executive Links with external organizations |
What happens after an adverse event?
Reporting and learning
A variety of reporting systems are operating at different levels within healthcare systems across the world. Some operate primarily at the local level (risk management systems in hospitals), others at the regional or national level. Local systems are ideally used as part of an overall safety and quality improvement strategy but in practice may be dominated by managing claims and complaints. Many different clinical specialities, particularly anaesthesia, have established reporting systems to assist them in improving clinical practice. These systems are designed to provide information on specific clinical issues that can be shared within the professional group. The increasing attention paid to patient safety has led to the establishment of many new reporting and learning systems: most notably, in the UK, the Reporting and Learning System (RLS) established by the National Patient Safety Agency. Other national reporting systems include the wide‐ranging Veterans Affairs system in the US and the Australian
