March 1, 2018

We all make mistakes

By Daniel Cabrera, M.D.

Author: Laura Walker, M.D. @dortzus

This post is a comment on Walker et al. Clinical care review systems in healthcare: a systematic review. Int J Emerg Med. 2018

 

We all make mistakes.

 

Most errors are avoidable in some way or another, the trick is figuring out how to do it.  To avoid repeating a mistake, you need to understand why it happened.  To understand why it happened, you need to talk about it.  And talking about it can be very hard to do.

 

Despite reports on the extent of medical errors1 and the need for increased transparency2 there is not a lot of literature out there exploring what review of a perceived medical error (care review) really looks like, or what it should look like.

 

Recognizing this gap, we undertook to perform a qualitative systematic review of the current literature on review of adverse events.  We performed a massive search of peer-reviewed literature and identified over 1300 articles that seemed to fit the bill.  In the end this was winnowed down to only 46 articles that were addressing what we were looking for – a description of what the process of exploring errors looks like.

 

We read through these articles and identified 16 common domains among them:

  • Systems analysis
  • Functional department
  • Educational output
  • Standardized process
  • Structured case classification
  • Feedback from and to the team
  • Human factors assessment
  • Outcome consideration
  • Non-punitive
  • Recognition of excellence
  • Referral process
  • Multidisciplinary
  • Process leadership
  • Reviewer training
  • Case blinding
  • Implementation of improvement recommendations

 

Wading my way through all these articles helped me better understand the concept of care review, and there are two groupings that I would call out as fundamentally important to understand.

 

First, there is the systems and processes aspect – the components of review that are very analytical and focus on the facts of the case and guide toward an objective evaluation and recommendations to decrease the chance of the error occurring again.  Second, there are those aspects that lead us to consider the role of human nature both in error and our response to it, in addition to the biases we have when we approach a situation.

 

The work that I do reviewing care often leads me to consider second-victim phenomenon – the psychological stress that affects the care provider after an error occurs.  Hearing that there are concerns about care you provided strikes fear in to all our hearts.  We need to continue to take care of our own, even as we strive to improve the care we provide for our patients.   Talking about our mistakes can be difficult, but it can also be educational, and from personal perspective and when done well – therapeutic.  And it can make a difference as we implement practice changes in response to concerning events – maybe we develop a process to improve checks on high risk medication doses, or implement a tool to aim for a safer care handoff, or we develop learning modules to highlight high-risk patient presentations.

 

Systems improvement and education are the goal outcomes after an event, and when a review incorporates the domains we identified in our review, we think that the downstream effect could be a process that fosters engagement and positive change.

 

(There is always the medico-legal aspect to consider when engaging in care review, check with your local legal team before setting out to make sure you are protected.)

 

References

  1. Makary, Martin A and Daniel, Michael, Medical error - the third leading cause of death in the US.  BMJ 2016 May 3; 353:i2139
  2. Kohn L T, Corrigan J M, Donaldson MS (Institute of Medicine) To err is human: building a safer health system. Washington, DC: National Academy Press, 2000

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Great work Laura!

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