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President's Page
June 2006
Near Misses—
Encouraging an Environment of Safety
2006 DCMS PresidentScuba diving is a great sport and a safe sport as long as the diver follows the rules. I often have told people who questioned my sanity after learning that I was a diver, that while diving I might kill myself, but I was unlikely to seriously hurt myself.
An experienced diver (over 400 dives in more than 20 years in multiple environments) was diving in a paradise: Little Cayman. The area has beautiful unspoiled waters, great food, and isolation: no radio, TV, and limited phone service. The landing strip is grass and not lighted—just the kind of place a busy physician needs to go to recharge.
The first dive of the trip was uneventful, with no breech of rules. When the diver reached the boat, he had some chest pain, but this resolved as he waited for the second dive of the day. As the boat moved to the second site, he tried to stand, but his legs would not support him. The excellent dive crew recognized the “bends,” or decompression sickness. The crew started oxygen and oral fluids, and got him to the clinic in town where the nurse started IV fluids and continued oxygen. He was flown to Grand Cayman at 500 feet (supported by an RN from the Cayman Hospital), and then taken by ambulance to the Emergency Department. The E.D. doctor did a brief examination, including a failed neurological exam. She said that if the oxygen and fluids had not been administered to the diver, he probably would be a paraplegic. Then he spent two days of 5-hour stints in the decompression chamber.
How could an experienced diver be so stupid? That’s a question I’ve asked myself many times, because that stupid diver was me. Thanks to the treatments and efficiency of the team, I have minimal residual effects. This is the classic example of a near miss that should be investigated (at least by me) so no one will make the same mistakes.
The airline industry has implemented a system based on that premise. The key to such a system is self-reporting in a nonpunitive environment. In the airline business, the system includes the pilots, dispatchers, and mechanics. The incentives to report are strong and include assurance of appropriate use, corrective action, confidentiality (i.e., no record kept in the pilot’s file) and anonymity provided after the event review, and corrective action.
The airline industry defined three categories of behaviors and labeled it as a risk-based learning system. Group 1 includes “normal error,” which is a product of the current system design and is managed through changes in process, procedures, training, design, and environment. Group 2 is “at-risk behavior,” managed through understanding our at-risk behaviors, removing incentives for at-risk behaviors, creating incentives for safe behaviors, and increasing situational awareness. Group 3 is “reckless behavior” (intentional risk taking) and is managed through disciplinary action and enforcement activity.
When the airlines started this system, the chance of dying on a domestic flight was 1 in 2 million. Today the risk of a dying in a crash is about 1 in 8 million. Recent studies reveal that between 44,000 and 98,000 Americans die each year as a result of medical error. This means that your risk of dying from a medical error during hospitalization is between 1 in 764 and 1 in 343. This is not acceptable.
Where health care was and where it probably still is: We still have a cottage industry mentality; we are totally reliant on professional/individual responsibility, individual perfection, train, and blame; and we have little understanding of systems.
The fear of liability has been a major roadblock to the necessary change in culture. The passage of the Patient Safety and Quality Improve-ment Act of 2005 should allow medicine to progress into the enlightened era of safety and quality first. Patients across the country are harmed daily, but these events are suppressed by the culture of “blame and shame.” Part of the culture is fear of litigation, but another is the reality that admitting a mistake could cost you your job.
On the other hand, components of a safety culture include an informed culture, a just culture, a reporting culture, a flexible culture, and a learning curve. These components ultimately should lead to a new way of thinking about a system of accountability.
Through such a culture, a new professionalism ultimately develops. The old mindset is that professionals do not make errors. The new mindset accepts that professionals do make mistakes, and realizes that this is the reason to report their errors and participate in the error management process. This type of awareness creates a professionalism that strives to perform at maximum reliability.
I want to reiterate that the purpose of a new system should not about assessing blame for errors or mistakes. It is about a commitment to patient safety and quality care, and a realization that without a change in the medical culture, it is impossible to attain the most basic objective of medicine—to first do no harm.
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