Wednesday, 29 August 2012

Recurring 'errors', learning and some fundamental issues

Recurring errors

Many of you could be familiar with the Elaine Bromiley case where a young lady for a routine ENT procedure died due to intubation difficulty ( There it was found that there was lack of situational awareness, poor decision making and poor leadership. This happened in 2005.The Harmer report on the tragedy is dated July 2005, the coroner inquest in October 2005. Marin Bromiley, Elaine's husband, an airline pilot, chairs the CHFG to promote human factors with a view to reducing avoidable errors.

Gordon Ewing died in May 2006 and the Scottish Sherriff’s fatal accident enquiry determination has been published ( I recommend that all of us read all the 108 pages patiently. Here the patient was scheduled for open reduction and internal fixation of terminal phalanx of little finger and died due to airway related difficulty.

Again, similar factors such as poor decision making and poor leadership has come up along with a host of other factors. The unwillingness to stop has been a common factor in both cases. I suspect it is just not these cases.

The link below is about 3 post cholecystectomy deaths in a 3 month period in 2006

I feel that recurrence is probably an essential feature of an error, my guess is that there are no errors that have ever happened only once. It might have happened only once to a person or a location but the error itself would have happened a number of times. Vincristine and nuclear leaks come to mind.

Who should learn?

In meetings where we discuss morbidity, mortality and learning from SUIs, a phrase you might often hear is 'for the benefit of the juniors/residents/trainees', as though 'seniors' do not commit 'errors' or have nothing to learn from the discussion. Well, all the above cases are about very senior and experienced doctors; so these reports are not for ‘the benefit of the trainees’ or ‘for the benefit of the juniors’. It is for everyone, specifically for senior post holders. Also, though the specific examples are about anaesthetics, surgery, etc; these cases are not about anaesthetists, surgeons, etc; the lessons are for all of us clinicians and non-clinicians; the generic issues are relevant as lessons for everyone. Techniques are speciality specific and person specific, errors and learning are generic.


Elaine Bromiley's case is well known and is full of learning which have been described by many before.

In the Ewing case, the Sheriff says:

‘While the lead clinician has the over all responsibility to ensure safe use of equipment, individual clinicians have a professional responsibility to use only equipment with which they are familiar and competent to use. This is particularly so where the piece of equipment is rarely used.’

There are many gems in the Gordon Ewing report.

In the gall bladder surgery cases, the report speaks about:

Tunnel vision

Damaged confidence from an incident preventing speaking up at a subsequent incident, potentially causing harm.

Poor notes, missing notes

Breast surgeon doing cholecystectomy

Consultant surgeon not attending

Consultant radiologist refusing to do scans at night

Consultant surgeon who does not do lap cholecystectomy dealing with complications of cholecystectomy

The repeated failure that patients post operative problems could result from the surgical procedure

The report is very recent. The incidents happened not too long ago either. They are from a normal hospital with normal people like you and me working in it and dealing with typical/usual patients.

The learning is profound, not new - many of us would have faced these situations a number of times; errors are recurrent. The impact of errors are horrendous for the people involved in it especially for patients and families (see previous blog on impact of complications

Fundamental issues

It is very heartening to note that courts and authorities who write the reports use a very respectful language towards doctors. They limit themselves to investigating and reporting event, post-event and agree with the given wisdom in practise as acceptable standards. I wonder whether this prevents an exploration of some fundamental issues.

Let me ask an awkward question. Why is a general anaesthetic even an option to deal with the terminal phalanx of the little finger? The report says that there was no record of non-GA options. My point is not that, my question is why was GA ever an option. Some of you are going to leap up and say 'patient choice' meaning that patients have to be offered a choice or patient choice to have a GA must be agreed with. Patients choices are mainly guided by their clinicians views, supplier induced demand, often felt to be well meaning, is alive and well in healthcare.

I know a general anaesthetic is routinely one of the anaesthetic options for any surgical procedure; but so was Halstead's mastectomy for any breast cancer in the past. Would we offer it as a choice now? Hypothetically if a patient wanted a Halstead when a local excision would suffice, would we do it? When an easier, safer, quicker, better, cheaper method is available is it still valid to offer potentially high risk complex procedure as an option?

Here is another awkward question. Why are breast surgeons, colo-rectal surgeons and all surgeons doing gall bladders and hernias when hernia surgeons do not do breast or colo-rectal surgery? I do not mind good old style of general surgery where everyone did everything - at least that is what they were supposed to do.  But that is not the world we live in these days (even in 2006) at least in the western world in the era of sub-specialisation. The situation of anyone doing the so called 'simple' things, still persists in many hospitals. Toe nail problems are as profound as any other 'major' medical problems for that given day for that given patient; it is not a matter of scale or judgement.

I wish the various authorities recognise the need to ask very deep and fundamental questions. Such as was this really indicated in the first place? Were the right people dealing with issues to begin with? I wish they would not accept given wisdom based on pacts of convenience as acceptable. Not with a view to punishing but with a view to improving clinical quality.

I wish they recognise and point out that these are massive system and leadership failures.

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Sunday, 19 August 2012

Fearless Healthcare is what we want

Recently read a book called 'Driving Fear Out Of The Workplace' by Kathleen D Ryan and Daniel K Oestreich. It was published in 1991 so obviously you can see that my wisdom is only now dawning. It is based on the 8th principle of Deming which is 'Drive fear out: employees must not be afraid to ask questions or take a position'. The book is written in an easy language and narrative style with enormous number of quotes gathered from their work with a variety of organisations but when read reflectively it can have profound impact on us and others.

The book wants us to
- be able to discuss the undiscussables
- realise behaviours that create fear
- understand the cycle of mistrust and break it
- acknowledge the presence of fear
- value criticism & reward the messenger
- reduce ambiguous behaviour
- move from participation to collaboration
- challenge worst-case thinking

The authors believe that driving fear out will overcome the invisible barriers to quality, productivity and innovation. The book is nothing to do directly with healthcare and has no direct examples but at a human level the threads are common. I recommend the book.

Healthcare & Fear

There are many reasons that driving out fear is even more important in healthcare. The very strong hierarchical structures in healthcare is an ideal culture medium for fear to thrive especially amongst the medical and nursing colleagues. The mostly pick and mix nature of evidence in healthcare delivery makes these hierarchical voices even more powerful. The difficulty with evidence generally creates poor systems, people who work within poor systems understandably do not do well and the culture of defensiveness and fear becomes greater.

Establishment is very strong in healthcare, in the UK clinical practice context you must submit to the clinical establishment (royal colleges, specialist bodies, et al) or to the research establishment (universities, funders) or face difficult consequences. Clinicians have a legal obligation to provide care recommended by NICE 'guidelines', there are armies of back office people who audit compliance to NICE guidelines which everyone fears of falling short. Providing the treatment recommended by NICE is a statutory duty i.e. law, I wonder why it is not called law and then define some exclusions. Why the euphemism? Now, would you have a fear of falling foul of a law?

The current economy does not help with many reduction in posts and changes in roles. It is also well known that in the context of the NHS the reorganisations are almost continuous and many non-doctor staff do live in fear of the next change that may adversely affect their role, skill and income.

Generally high anxiety and stress is understandably common for clinical professionals when dealing with patients given the very high emotional component involved in any healthcare advice or treatment especially acute care. The stress levels are even higher for patients and that is projected on to clinicians and reflects. This puts pressure to get it right every time, there is a fear amongst clinicians about getting it wrong; get it wrong in high finance and few points might drop of the footsie index, getting it wrong in healthcare could cost people a hand or a foot literally. But working with fear does not help the cause.

Constant comparisons with other industries (aviation, manufacturing, etc) while is very important for healthcare professionals who can understand the principles behind these comparisons and use them for improvement, is often taken out of context and has created an atmosphere where some of the public begin to have very high expectations that are difficult to service and some of the pubic fears healthcare. When let down, these lead to potential litigation which is a common fear amongst clinicians.

I could go on, but you get the idea. I do believe that fear should be driven out of the work place and especially so in healthcare; it would liberate the true power and potential of clinical professionals.

Fear could result in some of the effects discussed earlier in the blog, such as branding people as bad apples ( or agreeing with persons so as to please them as in the Abilene Paradox and other not so helpful behaviours. In healthcare, these combined with the issues around evidence and process efficiency leads to the phenomenon of Clinical Wrongology.

What are your fears at work? What are its effects? How do you and your workplace deal with it?

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Thursday, 16 August 2012




Substantial activity in clinical medicine is not performed on the basis of clear unequivocal evidence

Substantial activity in clinical medicine cannot after care delivery find evidence to back it

Substantial clinical care is delivered incompletely

Substantial amount of errors are found in the delivery of care

Substantial numbers of clinicians are either unable or unwilling to accept the above

In effect there is plenty or wrongness in theory, plenty of wrongness in practice and blindness to wrongness in clinical medicine. The wrongness is affecting patients by causing poor experience of healthcare, avoidable complications and avoidable deaths. Clinical wrongness is also affecting doctors and other clinicians causing variations in practice, restriction in the ability to practice appropriately and punishments for poor clinical performance.

There will be a day in the future when clinical medicine will practiced on the basis of proven science. We will truly rejoice on that day. Till that day arrives clinicians will need an approach that will help in appreciating, understanding and coping with the wrongness that is prevalent. The study of that approach is Clinical Wrongology.

Clinical Wrongology will remove the blindness to wrongness. It will make clinicians appreciate that there is wrong, wrongness and errors everywhere and these are normal to general life and clinicians are not exempt from this. Clinical wrongology will then encourage clinicians to cope with the wrongness around them and will show some methods to practice within the wrongness atmosphere with a view to increasing safety, quality and decreasing cost.
Clinical  Wrongology, the new specialty in healthcare is now declared open.

Watch this blog as there will be more on this subject.

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PS: While there are philosophers who are masters on the subject of wrongness and great experts in the study of error, my inspiration for thinking about wrongology and clinical wrongology was from 'Being Wrong', Kathryn Schulz's brilliant book. Kathryn if you are reading this blog I hope you do not mind me calling myself a Clinical Wrongologist, (perhaps the worlds first and only one till date); having vainly given myself that title I could be motivated to live up to it; unless I am totally wrong on that!

NB: Persons in healthcare who want to be involved and contribute to this effort, please leave a comment with a means of contacting you or send a direct message to me on twitter.

Wednesday, 1 August 2012

Abilene Paradox: Watch out, it could hurt you

Abilene paradox - the importance of managing agreements and agreeable colleagues

Last month I wrote about the Bad Apple theory and argued for a slightly softer approach in understanding and dealing with clinical 'bad apples' in healthcare. In a subjective sense, bad apples (irrespective of whether they are actually right or wrong) are persons who tend to disagree with their group and use negative behaviors to show their disagreement.

The Abilene paradox is some what the opposite phenomenon. This is when we do not voice our concerns, do not speak up, do not disagree. In fact in this paradox we actively do something that we do not fully believe in or want to do, because we felt that is what our boss, our group, our organisation wanted. We agree with our colleagues and peers to please them, we think our agreement will make them happy, will vindicate their opinion. If you are the leader, manager or proposer of ideas you come up with ideas, projects, activities, etc with the intention to please your team; your team in return go with your idea not because they think it is a good idea or want to agree with you, they simply run with your idea as they do not want to displease you or dampen your enthusiasm.. They might agree due to fear of authority, lack of knowledge, loyalty, the desire to play the part of a cooperative team member or perhaps even with the hope of getting something from you in return in the future. Obviously these are all the wrong reasons to play along with an idea if it was bad in the first place.

Watch out. This is something which has the potential to take you well away from your mission and plunge you into problems despite everyone's support and agreement; well actually because of everyone's support and agreement. Some might consider this a version of what we know as 'group think'; perhaps. In my view, group think is when all members of the group are convinced that it is a good idea, whereas the Abiline paradox is when group members may not believe it is a good idea but push the idea along forward and ahead simply because they think it will please other members of the group. This is something you want to avoid at all costs.

The fairly old but very interesting article called the Abilene paradox can be found at .

In summary, the author John Harvey says
‘’Organizations frequently take actions in contradiction to what they really want to do and therefore defeat the very purposes they are trying to achieve.’’

‘’.......a major corollary of the paradox, ... is that the inability to manage agreement is a major source of organization dysfunction.’’

This is the opposite of what many of us often assume that managing conflict is the usual big problem that frustrates us.

He suggests

‘’through the process of active confrontation with reality, we may take respite from pushing our rocks on their endless journeys’’

Abilene paradox is very relevant to healthcare. Just think, at your department level in MDT (multi disciplinary team) meetings and at national/international levels the unanimous decisions, at the consensus groups. Could the paradox be in play or could group think be in play? May be yes, may be no. But has the question been asked and answered if these phenomena could be affecting our decision making? I think we do not consciously explore this; we simply assume sometimes rightly, sometimes wrongly, that such ill effects did not afflict our decision making. In highly technical industries, in highly scientific industries and in highly evidence based industries adverse effects of the Abilene paradox will be negated pre-event by knowledge and post-event by data. In healthcare with its relatively poor evidence levels which results either in large variations in clinical practice or practice without improvement, the problems with group think and managing agreements are undoubtedly huge with its negative impact on patients.

Abilene paradox may turn out to be the bigger problem in recognition and management of healthcare's complexities.

You see the bad apples are easy since they are visible, audible and apparent. They make you uncomfortable or annoyed. You will be able to identify them and deal with them as early as you wish. Since we are all trained on how to deal with 'difficult colleagues' we at least imagine we can deal with people who disagree with us. Abilene paradox does not make you uncomfortable or annoyed till it might be really late. Since the intention of the group, who fall prey to the paradox is to cooperate and please, it will be really difficult to identify early and when identified we will be reluctant to deal with persons who have cooperated with us with good intentions. We have no knowledge or training on how to deal with easy colleagues who might pleasantly mislead. In organisations and teams peoples role is to cooperate appropriately and that can only happen when people support their team by critically questioning and vigorously analysing the issues. Only after a robust process should people offer their cooperation or agreement. 'Yes (wo)men' are probably more harmful to teams than bad apples in the longer run.

In old Jewish writings it is said that in a case subject to capital punishment if a guilty verdict was unanimous then the accused would walk free. This was generally thought to prevent group think, I feel their wisdom probably included concepts of the difficulty of managing agreements as in the Abilene paradox. It is said that good effective leaders surround themselves with a good team. Of course that is very important, but good leaders should make sure that the Abilene paradox does not frustrate them. Good leaders should demand that their team provide a genuine expression of opposing or divergent views so that higher quality decisions are made which would enable longer term success.

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