Clinical errors are a significant challenge, and nearly every person will experience a diagnostic error in their lifetime. As health care providers, we take an oath to “first do no harm” to our patients. And since it is never our intention to do harm to our patients, it is time the health care industry in general faced the facts of how our actions or inactions are putting our patients in harm’s way.
There are several ways an error can occur within the clinical environment. They can occur from commission or omission. They can occur because of a human error or because there are not systems in place to safeguard safety. Errors, when they occur, can result in near misses (which can go noticed or unnoticed) or they can unfortunately result in actual adverse events.
How Do Errors Occur? Active Failures, Latent Conditions and the Swiss Cheese Model
Think of your practice as a series of layers your patient must pass through as they receive care. From the moment they enter the physical office, to completing intake paperwork, interaction with staff members and providers during the evaluation and/or treatment phase of the encounter – all these interactions can be viewed as layers within the experience of the encounter.
Each one of these interactions or points of contact is an opportunity to gather information, assess and make a decision regarding the patient’s condition.
Consider the consequences of not gathering key information about the patient – or missing something they told you when you weren’t listening; or maybe a staff member who wasn’t trained appropriately to monitor the patient or perform therapy or vitals. These types of incidents result in what are known as active failures.
Active failures are the unsafe acts committed by people who are in direct contact with the patient or system. They take a variety of forms: slips, lapses, fumbles, mistakes, and procedural violations.
Additionally, these active failures may be caused or compounded by latent conditions. Latent conditions are the product of the lack of systems or operational sufficiency needed to create a safe clinical environment. Consider them “error provoking” conditions, such as time pressure, understaffing, inadequate equipment, fatigue, or inexperience.
Latent conditions, if left unattended, create long-lasting holes or weaknesses in the defenses (e.g., lack of training for staff, improper therapeutic or billing practices, lack of compliance policy).
When you have holes in the layers, a bad outcome occurs when the holes, in many defense layers, momentarily line up to permit a trajectory of an accident opportunity – bringing hazards into damaging contact with patients. This is known as the Swiss cheese model.
The Good News
The good news is that it only takes one thing to block the incident from occurring. That one thing could be a staff person noting an irregular pulse when taking vitals. That one thing could be a patient telling you they just had surgery that you weren’t aware of at the time. That one thing could be something the patient told you about their symptoms that just doesn’t seem to mesh with what you are finding on the exam.
Always be on the lookout for the “one thing” that will block the trajectory of an adverse outcome from occurring for the patient.
Ask Yourself...
Do you have an understanding of the common points of failure in your practice? Does it have to do with how you collect information from the patient, your listening ability, your technology’s ability to document and track patient conditions, your staff and providers’ competency and training, the layout of your office, your ability to arrive at an accurate diagnosis, and/or your ability to communicate to your patient?
Standardizing your approach in the patient care process by creating effective systems will close down the opportunity for your patients to experience adverse outcomes. egin today.
Editor’s Note: This is the second in a series of articles by Dr. Munsterman on patient safety and avoiding clinical errors. Read his first article here.
Reference
- Reason J. Human error: models and management. BMJ, 2000;320:768-70.
