COSM14: Computer Systems at Root of Medical Mishaps Concern Otolaryngologists

People also tend to fall prey to “hindsight bias,” a tendency to attribute causation to the individual we see as responsible after an outcome is known, he said. “This type of cognitive bias is related to the cognitive biases that impair our ability to make diagnoses of patients,” Dr. Eibling said.

The good news, he said, is that physicians have a lot of characteristics that should enhance their ability to try to solve these systems issues. They have a desire to do good for others and a respect for science, seeking out evidence when it isn’t readily available.

At VA Pittsburgh, for example, a color-coding system, the success of which has been supported by evidence from the anesthesia literature, has been adopted in the operating room as a way to prevent back table medication errors, he said. (There were no errors previously, and none have occurred since the new system was put in place, he said.)

“What I’d like to do is encourage you to take an active role in diagnosing and improving systems in your environment,” Dr. Eibling said. A key part of that, he said, is to seek out expertise from other areas and learn the “language” of these systems. “You’re going to find that in schools of business, psychology, and engineering,” he said, “they’ll be very eager to help you in your work to heal systems.”

As educated professionals, physicians have an opportunity to educate others, he said. “I would suggest that one of the ways we can change systems is by educating—particularly leadership—in the principles of system design, system diagnosis, and how to change systems,” he added.

He cautioned, though, against a potential backlash or being seen as a “troublemaker” if you don’t use the right approach. He encouraged the audience to familiarize themselves with “appreciative inquiry,” a way to ask questions and promote change that builds on imagination and strengths, rather than relying on criticism.

“Once you start trying to heal systems, it becomes a little addicting,” he said. “Don’t do what I do and try to fix everything. Pick one or two [problems] and focus on them.”