Dr. Shapiro noted that, at meetings, it’s the sessions with the most technical information that tend to draw the biggest crowds, as though “the way to avoid errors is just ‘learning more.’” But sessions on reviewing pitfalls such as bias should be required, she said. “It is these issues that are going to get us and our patients into trouble.”
Explore This IssueNovember 2014
Brian Nussenbaum, MD, who runs the quality improvement program in the Washington University School of Medicine otolaryngology-head and neck surgery department in St. Louis, said that cases that offer lessons for avoiding errors are discussed in conferences each month. The most serious cases are discussed, he said, but so are the most useful “near miss” cases—the cases that are often quickly forgotten. “These are the events that you could probably learn the most from, because generally when near-misses happen, people just take a sigh of relief, then move on, rather than thinking about exactly what happened,” he said. Additionally, cases with good outcomes are discussed when they hold valuable lessons.
The program tries to follow a “just culture” model, in which personal accountability and systems accountability are balanced—a model that “holds the individuals accountable for their actions but not for the flaws in the system.”
Rahul Shah, MD, MBA, chief of the Quality and Safety Office at Children’s National Health System in Washington, DC, stressed the importance of calling in a second surgeon when you feel under pressure and are faced with difficult decisions. That second set of eyes can be valuable and is not subject to the same biases that the first physician is. He decreed that no patient would code or die on the operating table without a second surgeon in the room.
Dr. Shah also said that it’s important for physicians with experience to share their heuristics—or way of thinking and making decisions—with new learners, such as residents. Those heuristics relate to “the underlying culture” at a center. “It’s invariably safer to fly home today or tomorrow than it is to have surgery in any one of our hospitals—and we have to ask ourselves why,” he said.
After the session, Dr. Arjmand said he organized the panel after being involved in root-cause analysis cases that “too often” fell into a category of everyone having done their job, with an error that “could have happened to anyone.” He wanted to zero in on the biases behind those types of errors.