In the field of healthcare management, medical errors are a real and alive threat to patient safety and, therefore, a grave threat to public health. Within the broad definition of organizational behavior management (OBM), a medical error is best described as “a problem in the process of care itself or failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.” (Institute of Medicine, 1999). Medical errors, or incidents, have unintended health care outcomes.
In my past job experience, there have been a number of incidents in which I’ve come across medical errors or incidents that were propagated or reinforced by employee perception and cognition. One ofthese incidents resulted in the death of a senile patient (Patient 1) who had presented to the health facility with severe lower back and neck pain. In this incident, the patient reported to the ER nurse with severe back pain, triggered after a fall when the patient was out for a walk. The patient had a history of chronic lower back pain, hypertensive heart disease and was attending the facility’s smoking cessation clinics.
While checking for vital signs, the triage nurse noticed that Patient 1 had moments of impaired consciousness and difficulty breathing and immediately suggested in her clinical notes that the patient undergo a cervical and thoracic MRI to rule out internal hemorrhaging. In the ensuing investigations, however, the ER doctor ruled out the need for an MRI and hurriedly prescribed a cocktail of antibiotics, including a benzodiazepine, and failed to instruct the nursing staff to provide ventilation support. After the patient was placed in the observation unit, the doctor sternly rebuked the triage nurse over the phone, claiming to know how to do his job.
As a result, the patient was wrongly diagnosed. However, the tragically ill patient could not be resuscitated only a few moments after been placed in the observation room. The cause of death was determined as an undiagnosed rupture of an abdominal aortic aneurysm that resulted in massive internal bleeding and cauda equina syndrome and cervical disk herniation that led to cervical spinal stenosis and progressive loss and eventual cessation of breathing.
In another instance, a comatose patient (Patient 2) suffered septic shock that were occasioned by pressure ulcers that were, firstly, poorly observed by the medical and nursing team that also included interns and, secondly, poorly treated. In both cases, the outcomes could have been avoided.
In the first situation, the following nursing and medical team members were involved were involved: triage nurse, observation unit nurse,resident nurse, and attending ER general practitioner. In the second scenario, the skin and wound team included: intensive care nurse, bed nurse, attending general practitioner, nutritionist, internist, dermatologist, physical therapist, among other medical specialists.
Tragically, health care professionals have come to accept medical errors as an unavoidable part of the medical training curve (Bosk, 1979). This arises from a non-OBM mindset. Due to the long-standing vertical occupational hierarchies within health caresettings, inter-professional communication is limited. Junior practitioners do not want to offend their seniors or betray their possible incompetence by reporting errors. Peers generally hesitate to report incidents as it may affect future career devilment or upset a do-not-report culture (Bosk, 1979). This phenomenon can be observed in scenario 2, when the junior team members fail to inform the senior staff that the patient’s condition is deteriorating, while the senior staff fails to conduct an audit of the entire team’s performance. This impairs error-related communication, thereby degrading patient safety outcomes and reducing learning opportunities.
The vast majority of medical errors detrimental to patient safety includes errors in or delayed diagnosis (failure to rescue), pressure ulcers or postoperative sepsis (Health Grades, 2008). In these two scenarios, my experience was the same. Health Grades (2008) continue to note that, in line with my experience, wrongful or delayed diagnosis and unexpected death during hospitalization for low-risk observation or treatment had the highest likelihood for mortality. Indeed, failure to rescue and failure or inability to prevent death or an adverse outcome are some of the most common preventable errors, at 17% and 12% respectively (Leape et al, 1993).
In Scenario 1, the ER GP drew attention not the patient’s symptoms, but rather, to the triage nurse’s suggestion of tests. His perception of the nurse’s suggestion as instruction triggered a judgment call. As a result, the GP unconsciously narrowed the parameters that he could use to influence a clinical decision. This subsequently led to an over-simplification of the matter, leading to wrongful DX, building on the GP’s flawed assessment of his own experience and expertise. In doing this, the GP reinforced prior experience between his prior interactions with the triage nurse. The GP had always felt the nurse did not know his place and was an insufferable know-it-all. The GP’s fundamental attribution error meant that he decided the nurse was disrespectful, did not understand the role of vertical hierarchies and was conceited. He did not see that the nurse needed inter-professional training nor did he see his own cognitive biases. These schemas- particularly persona and role schemas or mental models- led to an incomplete and inaccurate assessment that caused the patient’s death.
Human thinking is a dynamic and complex activity. When attempts are made to modify human thinking within an organizational setting, the outcome can be both undesirable and unforeseen. This situation is known as “policy resistance” (Sterman 1994,2001). Management that is blind to its own assumptions or biases, and those of others, will be ineffective. The task of the health care manager is to facilitate a common understanding of goals and practices among members of the organization. Otherwise, the varied perceptions of these members will alter organization-level sensemaking and performance.
To remedy such a situation, the manager is required to ensure these divorced perceptions are shared across the various hierarchies through discussion and communication. The term “learning organization “ therefore represents an organization that shares individual assumptions and mental models to create new mental constructs, enhance collective sensemaking, create new knowledge, solve problems and adapt to a changing world (Easterby-Smith, Crossan&Nicolini, 2000). The learning organization also understands the role of problem solving, welcoming the opportunity to handle complex problems encountered during the provision of services to patients. Communication plays a critical role in identifying the problem, generating collective goals, assessing options, and choosing and implementing a practical solution.
OBM techniques such as creating feedback, providing training and setting common goals are the building blocks to behavior-based approaches to system change. Ideally, an OBM approach encourages caregivers to have “response generalization”, with every set of intervention multiplying compliance with the next (Ludwig & Geller, 2000). The following would be this author’s preferred intervention package for the two scenarios:
Bosk, C. (1979). Forgive and remember. London: University of Chicago Press.
Easterby-Smith, M., Crossan, M., & Nicolini, D. (2000). Organizational Learning: Debates Past, Present and Future. J. of Management Studies, 37(6), 783-795
Health Grades (2004). Health Grades quality study: Patient safety in American hospitals.Available at: www.healthgrades.com/media/english/pdf/HG_Patient_Safety_Study_Final.pdf. Accessed December 18, 2015
Institute of Medicine. (1999). To err is human: Building a safer health system. Washington, DC: National Academies Press.
Leape LL, Lawthers AG, Brennan TA, et al. (1993). Preventing medical injury. Qual Rev Bull19: 144-149.
Ludwig, T., & Geller, S. (2000). Intervening to improve the safety of delivery drivers: A systematic behavioral approach. J Organ Behav Manag; 19: 1-124.
Sterman JD (1994).”Learning in and about complex systems”. System Dynamics Review V10(2-3), pp 291-330.
Sterman JD (2001). System Dynamics modelling: tools for learning in a complex world. California Management Review, V 43(4), pp 8-25.