There’s an old joke told by PhDs:
A doctor and a researcher are walking along a river when a drowning person floats by. The doctor jumps in and heroically saves him. A few minutes later the same thing happens again. And again. After the third rescue, the doctor looks up to see the researcher running away. Exhausted, he shouts, “Where do you think you’re going!?” “I’m going to the bridge up ahead to see who’s throwing people off it,” she replies.
This same joke holds lessons for quality improvement in healthcare.
Quality is the new buzzword in health care. Purchasers want it and health care providers are clamoring to prove that they do it best. Quality care can be defined by facilitating good outcomes for our patients; and therefore improvement efforts often focus on bad outcomes to find the cause and eliminate it. This view is comforting to some as Dr. Wears writes in his editorial, “The Error of Counting Errors”, because it leads us to believe that “our systems are basically safe, there are just a few aberrations to deal with, there is no need for fundamental change that might upset the established order.”
Take a clinical hypothetical, for example, the case of Mr. Y, a diabetic man who presents with a kidney stone. His white count was a little elevated and there was some mild pyuria but Dr. X got his pain better and he looked good, so she sent him home. When Mr. Y returns the next day with sepsis from an infected stone, the next provider thinks, “Oh, Dr. X is in trouble for this one.”
What we didn’t see was that the waiting room was so full when Dr. X discharged Mr. Y that Dr. X’s main concern had been making a new bed available. She considered that this diabetic could be at increased risk of infection, but Mr. Y really wanted to go home, plus, her experience told her that there was no way the urologist on call would ever admit that patient anyway, and she’d been killing the hospitalist that busy night with admissions, so she was reluctant to pass this “soft call” over to him.
Her decision was not influenced by a lack of knowledge or failure to consider the risk-benefit aspects of the case. She also took into account the system pressures at the time, her experience with the other actors in her environment, and the desires of her patient. It’s easy to say that Mr. Y’s return was her fault, but her decision would have and will be made again and again by her partners until the pressures that influenced that decision are removed.
In other words, this sort of scenario will keep happening in healthcare as long as the PhD continues to jump in the water instead of going up to the bridge.
While blaming bad patient outcomes on human error comforts other members of a system, it horrifies those who commit the errors, because they are made the scapegoats for a flawed system. No emergency medicine doctor wakes up in the morning, stretches and says, “Today I’m going to make an error that could hurt my patient.” And yet when human decisions by action or inaction lead to a bad patient outcome, we aim with hindsight to look back and see all the ways and chances to avoid that outcome.
This process can leave the involved provider in a state of shock. They did not intend to err, their decisions seemed right at the time, and finger-pointing only adds to the stress they incur from learning that one of the people they cared for did not fare well.
Our patients want to know that we will care for them and that they are safe under our care. One of the most burning questions asked by a patient or their family when harm occurs is, “What will you do to make sure this won’t happen again?” If our answer is to perform a retrospective witch hunt and burn the involved provider at the stake with second-guesses, we can only assume that the mistake will occur again and that the scars incurred by the provider will ensure that they forever avoid quality improvement processes. If instead, we combine a reasoned quality review program with a broad look at the structural and systemic issues that influence individual decision making, we will be on a path toward figuring out why exactly those drowning people keep coming down the river.
At our group, we constantly strive to provide excellent care and our Peer Review process is a center point of our quality model. We have made efforts to reduce hindsight bias when reviewing cases by only considering the first visit of a bounceback and focusing on providing education for all; however, during causal analysis ‘error in diagnosis’ and ‘error in judgment’ are the most common reasons applied to explain a bad outcome.
Dr. Wears argues that these are never the true reasons behind a bad outcome but only the beginning. Organizations depend on having “the right people on the bus” for success, but organizations that only look backwards, or look backwards myopically, are in danger of losing all their passengers.