Human error has become unacceptable in medicine. Unfortunately, human error is inevitable in medicine. We all work as hard as we can, but those slips, faults, mistakes, incidents, accidents, and adverse advents that harm both patient and provider still occur.
Why do adverse events happen? If I consider emergency medicine, I can identify multiple factors that increase the probability of making a mistake: constant interruption, shift work, disrupted sleep patterns, unique situations, volatile situations, diagnostic uncertainty, and cognitive overload. Algorithms, mnemonics, computers, EMRs, and handheld devices help decrease cognitive load and work stress. In our ER, we have clinical pathways and order sets built into our EMR. I can order serial NMTs with a couple of clicks and initiate order sets for diagnoses or presentations that need rapid management, such as reversal of Coumadin in a trauma patient or TPA for a stroke. These sets include all the labs, medications, and imaging studies I need, and they cross check my ordering as I go, relieving a lot of the cognitive loading in these high-risk cases. Carefully established department guidelines aid us with decision making and safety in volatile situations, and an emphasis on teamwork engenders a multidisciplinary approach to problem solving. By watching out for each other, we watch out for the patients. Even with these safeguards, however, adhering to the guidelines and monitoring the team becomes really tough when the ER is overflowing with patients and all providers are stretched to the limit.
Safety problems in any specialty can be split into three areas: procedural, affective, and cognitive. Procedural errors occur whilst we are doing a procedure. We drop the lung during a subclavian or apply a cast improperly. Careful training and appropriate supervision reduces the risk of these types of adverse events. We start mastering such skills in school and continue to refine them (hopefully) until we retire. I remember as a student being instructed to remove sutures because they were too close to the wound edge or too far apart; it felt time consuming and painstaking then, but now I appreciate the attention to detail. I learnt to do the job well. We do our students and new graduates (and colleagues) a favor when we set the bar high. Being willing to learn new skills or practice old ones again helps us check ourselves for bad habits and keeps us current. Recently, I was asked if I wanted to participate in a cadaver lab, practicing central lines, chest tubes, cut downs. Initially, I thought, “I passed gross anatomy in school,” but then on quick reflection, I realized this is different from my PA program classes: had I done procedures on a cadaver? Well, once or twice but for quite different reasons. I might learn some useful skills in this lab that would benefit my patients. The adage pride becomes before a fall holds some truth; being too proud to learn puts patients at risk.
A clinician's affective state may influence his reactions with the patient. Stress, poor sleep, or illness may cause a temporary disruption in medical decision making or have a negative influence on our interactions with patients and colleagues. Who hasn't had a bad day? In this instance, the safety of all patients may be compromised. Responsible providers know their limitations and keep the safety of patients at the forefront. If your kid is in hospital sick, your mother has just died, or you have a pounding headache that is reducing your brain to fuzz, calling in is probably in the best interest of your patients. Knowing when to call it is a testament to your professionalism.
Sometimes we harbor negative feelings about a particular group of patients that decrease safety and increase risk. Maybe you have had a bad experience with a particular patient set, or perhaps the last time you had a patient with a particular diagnosis things, went badly. This can influence your next encounter with a patient who reminds you of that experience. For example, you have seen a zillion patients with back pain who, on review of their prescription records, turn out to be narcotics abusers. Consequently, you may have a tendency to see all patients with back pain as drug abusers. You may become cynical. These negative feelings can influence the quality of both the clinical encounter and the patient's medical care. Patients with genuine back pain may get short shrift. The patients who are known drug abusers suffer too. We may miss physical illness in these patients, dismissing clinical signs too readily or not giving them a thorough physical exam. Exploring negative feelings we have towards particular patients or diagnoses is important. Ask yourself: what complaint irritates you most? Can you identify a particular patient set or certain patient traits that cause you an internal groan? Do these feelings influence the quality of the patient encounter or your medical decision making?
In reverse, perhaps you have positive feelings towards a patient set or a particular patient. This could result in the ordering of too many tests (don't want to miss something in grandma) or too few tests (don't want to find that STD in your neighbor). Have you ever not ordered a test because of the good feelings you have towards a patient? An attending was once surprised I ordered urethral cultures in a 70-year-old man. I explained that the patient may look like Grandpa Walton, but STDs are on the rise in the over-65s and he had symptoms that made me suspicious for gonorrhea or chlamydia. How often do you not order something because the patient does not seem the type? When we let positive and negative feelings we have towards our patients influence our medical decision making, we are at more risk of making mistakes.
Practicing medicine taxes the brain. As our experience builds, we develop heuristics or strategies to shorten the thinking process. These strategies help us respond to particular situations in a certain way. We create pathways in our head similar to the algorithms we learn on paper. Generally, these shortcuts are helpful, but sometimes they can be dangerous. Heuristics create a bias that may result in a serious miss. For example, a patient with right flank pain, nausea and vomiting, and hematuria may set us along a well-established workup for renal stones: we quickly order a UA, KUB, US, CBC and basic panel along with anti-emetics and analgesics. Sounds simple, but there's danger here. This presentation could be renal stones but aortic dissection is also in the differential. Not a diagnosis you want to miss.
Representativeness is a cognitive bias or heuristic that causes problems for many providers. If a 55-year-old diaphoretic man arrives clutching his chest and complains of crushing substernal chest pain, he is typical or representative of a patient with angina. An elderly diabetic woman, however, may present with much vaguer symptoms (nausea, weakness) that do not represent the typical population well. Some patients just do not fit the mold. For example, a young patient is at risk of having an angina diagnosis missed altogether. In school we frequently learn diseases by their hallmark signs. This helps us simplify and condense the amount of material we need to absorb; however, this emphasis on representativeness brings risk: patients often do not present nor do diseases manifest like textbooks.
Availability refers to the information we have readily at our finger tips. I recently saw a patient in the ER with cardiac tamponade. His chief complaint was dizziness. The patient did not present with hypotension, JVD, or muffled heart sounds. Where the heck was Beck? My only clue was a recent cardiac procedure. When his blood pressure suddenly plummeted, cardiac tamponade shot to the limelight. Prior to this month, I hadn't thought much about cardiac tamponade. Now, every time I see a patient with a complaint of dizziness in the setting of a recent cardiac intervention, cardiac tamponade will come to mind. The diagnosis is more available to me. Another example is when a clinician has bad experience, such as missing an aortic dissection in a patient. The clinician sensitized by this experience keeps that diagnosis available. The provider may over-diagnose or over-test for this particular complaint and consequently miss or be slow to find other diagnoses.
Committing to a particular diagnosis early on in a patient's course is another heuristic or bias that may get us into trouble. We fix ourselves or anchor ourselves to this diagnosis and consequently may miss the real diagnosis. The location of the patient may cause us to anchor early. The patient is in the pelvic room or the fast track section; therefore, they must have a pelvic problem or a minor problem, and we throw out signs that hint at something else. Other providers may cause us to anchor on a diagnosis too early. For example, a patient presents with tenderness in her lower abdomen and has dysuria. She has already had a UA that shows a UTI. Another provider (nurse, PA, tech) has told you: this patient has abdominal pain from her UTI. It's nothing. This seems easy but have you ruled out an appendicitis or PID? Anchoring can cause us to latch on to the obvious and miss the real pathology. A patient may have a UTI as well as appendicitis. Similarly the patient with psychiatric illness may also have physical illness.
Calling off the search for other diagnoses too early is referred to as search satisficing. For example, we find a distal radius fracture in a patient but we miss the radial head fracture. The second fracture is the most missed fracture. Another example: the patient with a headache and history of sinusitis has us convinced this headache is more of the same, so we miss the tumor in his head. Contributing to this is a confirmation bias. The patient is tender over his sinuses, has terrible halitosis, and isn't that mucous at the back of his throat?
Looking for clinical signs that do not support your diagnosis is a much safer and more powerful strategy. What tells me that this isn't sinusitis? Try documenting why you are not concerned for appendicitis in the patient with lower abdominal pain or for cardiac pathology in the young patient with chest pain. This is much harder. If you cannot do this, ask yourself if you are ready to lose a patient, go to court, or give up your PA license?
Mistakes are a very human trait. We are unlikely to eradicate them entirely from medicine, but with self-monitoring and teamwork, we can reduce the risk. Be sure that sugar sweet wife who lost her too young husband to an MI is as likely as anyone to say, “Hasta la vista, baby; see you in court, Sir”. Can we blame her? JAAPA
Alexandra Godfrey practices emergency medicine at St. Joseph's Mercy Hospital, Ypsilanti, Michigan. This blog post expresses her personal views and does not express or represent the views or policies of AAPA.