ethical reflections on error: in defense of a new approach n. yasemin yalim, md. phd professor of...

ETHICAL REFLECTIONS ON ERROR: in defense of a new approach

N. Yasemin YALIM, MD. PhD

Professor of Bioethics

Ankara University School of Medicine

AGENDA

Malpractice

Errors in general

Seven myths about error

The benign face of the human factor

Real world decision making

Different approaches to error

04/18/232 Prof. Dr. Neyyire Yasemin YALIM

MALPRACTICE

is defined as a professionals lack of

knowledge, lack of experience, or

negligence that causes harm or leads to a

mistake.


ERROR

is a failure of a planned action to be

completed as intended or the use of a

wrong plan to achieve an aim.


ERRORS

Failure of conforming a planned action standard for the situation

Lack of necessary skills

Lack of knowledge

Negligence

Psychological factors about the performer

Significant uncertainty

Lack of on-site safety regulations

Lack of standards


HOW HAZARDOUS?! Dangerous Regulated Ultra-safe

Health Care

Driving Scheduled Mountain Chartered Airlines Climbing Flights European

Railroads Bungee

Jumping Chemical Manufacturing

Nuclear Power

Tota

l liv

es lo

st p

er y

ear

1

1

10

10

100

100 1,000

1,000

10,000

10,000

100,000

100,000

1,000,000 10,000,000

Number of encounters for each fatality

(>1/1000) (>1/100K)


Organizations, Institutions,

Policies, Procedures

Resources & Constraints

Practitioner

Monitored Process

BLUNT END

SHARP ENDExpertise

ActionsErro

rs

Results

Practitioners work at the sharp-end of the system. The blunt end of the system generates resources, constraints and conflicts that shape the world of technical work and produce latent failures.


SEVEN ERROR MYTHS

Errors are intrinsically bad

Bad people make bad errors

Errors are random and variable

Practice makes perfect

Errors of professionals are rare

But they are sufficient to cause harm

Easier to change people than situations


ABOUT MYTHS

All myths contain a grain of truths.

But the myths to be discussed here arise largely form the emotional baggage that people carry around in their everyday lives.

They present serious impediments to effective error management.


ERRORS ARE INTRINSICALLY BAD

They are essential for coping with novel situations: trial-and-error learning

They are the debit side of a mental ‘balance sheet’ that stands very much in credit: but each ‘asset’ carries a penalty.


UNDER-SPECIFICATION

Errors arise when mental processes necessary for correct performance are under-specified.

Under-specification takes many forms : inattention, incomplete knowledge, sparse sensory data, forgetting, etc.

When processes are under-specified, the mind ‘defaults’ to a response that is frequent, familiar and appropriate for the context. This is very adaptive.


BAD ERRORS, BAD PEOPLE

Often it is the best people that make the worst errors.

About %90 of errors are culpable.

But some people knowingly adopt behaviors more likely to produce error: substance abuse, excessively long working hours.


ERRORS ARE NEITHER RANDOM NOR PARTICULARLY VARIABLE

Errors happen when…

You know what you are doing, but the action don’t go as planned (slips, lapses, fumbles)

You think you know what you are doing, but fail to notice contra-indications, apply a bad ‘rule’ or fail to apply a good ‘rule’ (rule-based mistakes and/or violations)

You are not really sure what you are doing (knowledge-based mistakes in novel situations)


PRACTICE MAKES PERFECT

Practice does not make perfect, but it alters the type of error.

Knowledge based errors decrease due to the increasing level of proficiency, while skill based errors increase.


THREE PERFORMANCE LEVELS

Situations

Routine

Trained for problems

Novel problems

Cognitive control modes Conscious Mixed Automatic

Skill-based

Rule-based

Knowledge- based


PRACTICE ALTERS THE ERROR TYPE

Knowledge-based

Rule-based

Skill-based


ERRORS OF PROFESSIONALS ARE RARE, BUT THEY ARE SUFFICIENT TO CAUSE HARM

Errors are rare but sufficient to cause accidents. Assumption: well-trained operators with good procedures should not make errors.

Errors are commonplace and only very occasionally necessary to complete an accident sequence that usually has a long history.


Complex systems fail because of the combination of multiple small failures, each individually insufficient to cause an accident. These failures are latent in the system and their pattern changes over time.

“Normal” operations

TRIGGERS

DEFENSES

LATENT FAILURES

ACCIDENT


NEAR MİSSES

EASIER TO CHANGE PEOPLE THAN SITUATIONS

Two ways of looking at the human contribution

The PERSON approach: Focuses on the errors and violations of individuals. Remedial efforts directed at people at ‘sharp end’.

The SYSTEM approach: Traces the causal factors back into the system as a whole. Remedial efforts directed at situations and organisations.


MANAGING THE MANAGEABLE

Fallibility is part of the human condition.

We are not going to change the human condition.

But we can change the conditions under which people work.


HUMAN VARIABILITY

Human as Human as

hazard hero

- Slips - Adjustment

- Lapses - Compensations

- Mistakes - Recoveries

- Violations - Improvisations


THE VARIABILITY PARADOX

Errors are implicated in some % 70-80 of accidents.

Elimination of human error is seen as a primary goal by many system managers.

As with technical unreliability, the strive for greater consistency of human action.

But human variability protects the system in a dynamic uncertain world.


REAL WORLD DECISION - MAKING

Put your head in the

data stream

Look out

a familiar pattern

Monitor progress of action

Generate a possible solution


FEATURES OF REAL WORLD DECISION - MAKING TASKS IN ENGINEERING

Ill-structured problems

Uncertain dynamic environments

Shifting, ill-defined or competing goals

Time stress

High stakes

Multiple players

Organizational goals and norms


CLASSICAL (LABORATORY) DECISION - MAKING MODEL

A

I’ll go for option B


After the

accidentBefore the

Accident

Post-accident reviews identify human error as the ‘cause’ of failure because of hindsight bias. Outcome knowledge makes the path to failure seem to have been foreseeable – although it was not foreseen.

Hindsight Bias


PENALTIES OF BLAMING INDIVIDUALS

Failure to discover latent conditions

Failure to identify error traps

Psychological precursors of error (inattention, forgetfulness, etc.) are the last least manageable contributors

A blame culture and a reporting culture cannot co-exist


A SELF-PERPETUATING CYCLE

Blame

Pursuit of ‘excellence’ Denial


AN EXAMPLE FOR THE DIFFERENCES BETWEEN A BLAME CULTURE AND A REPORT CULTURE

Nurse All-at-Once was fixing the leaking oxygen mask when the orderly came back with the bottle. She pointed at the chloride bottle, so he pour the chemical in it and left.

Cyanide gallon in front of the shelf and its label is semi-readable because of a leak from the ceiling.

Like this “C.a.ide”

New orderly thought that it is the chloride gallon.

Dr. Wrong-Doer pull some chloride from the bottle and injected it to Mr. Unlucky.


It is not the end of the story …

Create precautions:Like special notices saying that“Are you sure it is safe?”

You can still do something!!!!!?????


NEW PRECAUTIONS CAN BE DAMAGED …


WHO IS S(HE) ???

Long working periods under stress factors.

Inadequate resting periods

Continuous heavy working load

Accumulation of minor events.


The PERSON Approach - A

Operation room staff found out that they mixed the chemicals.

They decided to cover up the situation because all found themselves guilty.

They informed the family that Mr. Unlucky could not make it this time.

No one realized the situation.

They rewrote the tags and had the ceiling repaired next week.


The PERSON Approach - B

Hospital Committee for Malpractice questioned Dr. Wrong-Doer for injecting cyanide to the patient.

They concluded that any careful physician would smell the odor special to cyanide when he/she opened the bottle.

The doctor found guilty for being negligent

He was expelled from the hospital.

The hospital and the malpractice insurance of the physician paid a couple of million dollars to the family.


The PERSON Approach – B

Nurse blamed the orderly for his negligence, but as he never showed up at work again.

The leak on the ceiling was repaired after a number of near misses and two serious accidents.


The SYSTEM Approach

The Hospital Patient Safety and Medical Error Committee learned the situation when Nurse All-at-Once reported the event to them.

The safety team at the operation room traced the evidences and found out the sequence of events that caused the accident.

The Hospital Management gave an apology to the family, they went on an agreement for compensation and both the hospital and the physician’s insurance paid the compensation.


The SYSTEM Approach

The leak was repaired, the tags were renewed.

The safety inspector decided to add an inert colorful chemical to the poisonous chemicals; they divided storages for daily used chemicals and rarely used chemicals etc.


INAPPROPRIATE REACTIONS TOWARDS MALPRACTICE

Organizational reactions to failure focus on human error.

The reactions to failure are; blame and train sanctions new regulations and rules technology

Result is increased complexity and new forms of failure.


SOME PHILOSOPHICAL UNDERPINNINGS

The aim is to reduce harm not errors.

Cooperation across professional roles are essential.

Use prevention – identification – mitigation as principles.

Individual providers, managers, and executives have an obligation to continually work to make the system safer in return for a blame free working environment.

Progress on safety will require a synergy between methods of reliability and safety with professional knowledge and practice.


Every system is perfectly designed to achieve exactly the result it gets.


04/18/23Prof. Dr. Neyyire Yasemin YALIM41

ethical reflections on error: in defense of a new approach n. yasemin yalim, md. phd professor of...

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