Should we learn how to make mistakes? #WILTW

This is the 119th #WILTW

“Hospital Doctors miss signs of illness because of chronic staff shortages”

This headline played across news outlets and social media this week.  Based on the results from doctors survey it encapsulated the pressure currently felt by many health care professionals. Politics aside there remains increasing demand for services with a relative fixed amount of staff to deal with it. Additional challenges were revealed by the extent of General Medical Council training concerns at over 70 hospitals in the United Kingdom.

Regardless of the underlying reasons; patients expect not to have signs of illness missed which in retrospect should have been detected. This is not saying all diagnoses should be be correct or timely. Some conditions are difficult to detect in their early stages and some require extensive work up to define the extent of illness. However even with an increasingly litigious society a large amount of NHS funding is expending settling complaints which could have been avoided had appropriate initial interventions occurred. Why does this happen? Why do healthcare professionals miss seemingly obvious signs and symptoms? Obviously the reasons are multi-factorial. External pressures as noted in the doctor’s survey will play a part. However there are some intrinsic factors in the way that doctors make decisions that often cause problems.

Some of these Diagnostic Reasoning errors were reviewed in a blog published this week  summarising a lecture delivered by Jonathan Sherbino. Jonathan works in an Emergency Medicine Department in Canada and has a research interest in decision making processes. System 1 (fast) versus System 2  (slow) thinking was reviewed along with some myth busting of how diagnostic errors occur.

Right Decision, Wrong Decision Road SignOne of these was speed of diagnosis. Evidence suggests that going slower makes you slow, not better. This isn’t saying going faster makes your more accurate but that you often gain little in the way of accuracy by spending more time thinking about a problem. Even more interesting was the fact in some studies interruptions, which would seem an inherently bad thing when you are busy cogitating a problem, didn’t seem to make diagnostic accuracy any worse. The final take home message was that reflection, in this case a cognitive forcing strategy of structuring a second review of your decision, only really benefited those with prior experience.  Experience coming up again and again as the best way of avoiding diagnostic error.

This then asks some difficult questions of how we should best structure our healthcare service. Having more senior staff is something many Royal Colleges have been calling for for some time. But those senior staff need to gain their experience from somewhere which resonates with the blog’s author Jesse Leontowicz closing point to ensure that learners get experience in the Emergency Department and not just hope it happens. I’d add something else as well.  Health care professionals, especially doctors, need to understand why they make mistakes rather than hope they don’t happen and be chastised when they do.

Learning the processes that facilitate making mistakes makes it much easier to avoid getting caught up in them.

What have you learnt this week? #WILTW

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This blog co-incides with the release of the summary of my induction lecture to our Emergency Department new starters (click here if video doesn’t play).

A previous WILTW has also covered cognitive error:

What I learnt this week: Avoid a confirmation cock-up this Christmas #WILTW

Patient care is not sport but should it be funded like it is? #WILTW

This is the 118th #WILTW

A last minute victory in a sporting event is always exciting to watch. Whether it be a perfect two and a half back-somersaults with two and a half twists in the final round of the diving or a dive across the line to win the 400m it’s brilliant to see years of hard graft coming to fruition.

I always experience a pang of guilt during the Olympics having chosen medicine and a social life at University rather than medicine and steeplechasing. I have huge respect for the sacrifices made by sports men and women in dedicating their lives to, what in some cases, is less than 10s of action. I have also watched with interest the increasing public awareness of marginal gains. Concentrating on ensuring every part of your performance is as good as it can be is something I discussed in reviewing Leicester City’s football success. 

Marginal gains are not a new concept in healthcare so it is easy to see why people wonder if we can transform the NHS in the same way British sport has radically altered since the nadir of Atlanta 1996. Huge financial investment, £5 million (Atlanta) to £350 million (Rio), has resulted in a 2000% increase in gold medals compared to those 20 years ago. Trying to make a comparison with healthcare is patently silly and also quite difficult as direct funding figures are hard to come by (although I was surprised to find between 1999/00 and 2009/10, NHS real-terms expenditure rose by 92%). However it does seem odd that while we are happy to expand funding to reward olympic sporting success we are not happy to expand NHS funding despite relatively high performance compared to other international comparators. The figure below shows flat expenditure growth in the last 5 years.

 

NHS funding and expenditure via House of Commons Library
NHS funding and expenditure via House of Commons Library http://www.nhshistory.net/parlymoney.pdf

One thing that doesn’t happen in healthcare compared to sport is penalisation of failing to succeed. This is not something that would benefit patients or staff. You do wonder though if the NHS is such a national treasure we should support its success in the same way we do for our Olympians.

What have you learnt this week? #WILTW

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Why does no one answer the phone in hospitals? #WILTW

This is the 117th #WILTW

John has been admitted to hospital with pneumonia. He is on a bed near the nursing station on ward 22A. Around the station are a couple of doctors and nurses looking through the notes trolley. He watches the ward clerk stand up and walk off the ward to find some stationery. 

The phone at the desk starts to ring. The doctors and nurses on the ward round continue their discussions.

The phone continues to ring. John watches a doctor walk past the station, look at the phone, look around the room and then continue to walk up the corridor.

The phone continues to ring. A nurse arrives at the station. She looks stressed. She sits next to the ringing phone, pulls out a diary, opens it, rolls her eyes and then walks away. 

The phone continues to ring. Through the doors to the ward a consultant arrives with some medical students. They all look at the ringing phone. They look at doctors and nurses around the notes trolley and look back at the phone. They then move off to examine the patient next to John. 

One of the doctors at the notes trolley then moves round to sit next to the ringing phone. He starts writing in the notes. He looks at the phone. The phone keeps ringing. He looks up at the remaining team around the notes trolley. He then continues to write in the notes.

The stressed nurse comes back to the nursing station, mutters something under her breath and then leaves the ward. The doctors and nurses around the notes trolley push it towards the patient opposite John. They are joined by the note writing doctor. 

The phone continues to ring .

The ward clerk returns to the ward.

The phone stops ringing.  

I had to call out our staff this week for leaving the phone ringing despite a number of people being quite capable of answering it. The act of picking up a phone seems an inherently simple task. Certainly to an external observer like John there seems no reason for someone not to do it. The assumption is staff are lazy, rude or completely uncompassionate. Imagine if John had been waiting for a phone call from a loved one with some important family news or maybe about his transfer home.

Some of the reasons are more complex than the assumptions though. A honest junior said to me once, “The problem with answering the phone is that the majority of the time you can’t help at all and get dragged into a situation where you become responsible for the problems/issues/concerns of the person on the other end of the line.” This doesn’t excuse not answering the phone but if you knew you could always respond with a yes or no I suspect answering times would decrease significantly.

The prompt for this muse comes from a powerful article by Dr. Ranjana Srivastava on professionalism and responsibilities in medicine. She questions why health care professionals ‘overlook’ potential poor or harmful practice by colleagues or in systems:

So, while professional integrity is necessary, I think the question we ought to periodically ask all doctors is actually a far simpler one. “What kind of a person do you want to be?

I want to be the consultant that sets a good example to the medical students. I want my juniors to understand how to prioritise tasks and I want nurses and doctors to realise that some jobs can be done by either professional.

the-standard-you-walk-past-e1397434304165

This is really easy to say but much more difficult to put into practice. Maybe answering the phone is one place to start.

What have you learnt this week? #WILTW

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Post release note:

#WILTW rarely produces responses and it is even less common for people to disagree (please see comments below). The topic of discussion is definitely in the grey zone though and I think it was a justified challenge. The tweet below perhaps was something I should have included within the blog.

How not to manage flow (or no more forms please) #WILTW

This is the 116th #WILTW

While those working in Emergency Medicine spend their lives trying to create, fix, or wanting to cry at the ‘flow‘ in their departments everyone experiences its importance.

For example, standing in the queue of a fast food restaurant your hunger and irritation grow as you realise the rate of people arriving is clearly greater than the amount of people leaving with food.  Whats more you notice the obvious variation in the way the queues are moving; and are convinced your ‘one starred’ server is definitely slower than than ‘five starred’ server in the row you should have joined.

The BMJ’s Quality and Safety Journal recently published a paper entitled: Six ways not to improve patient flow. It is a qualitative study (exploratory research measuring the quality of something descriptively rather than numerically) trying to work out why initiatives at improving patient flow through Emergency Departments often fail. The authors interviewed senior staff and analysed documents in a region in Canada and then drew a number of conclusions as to why interventions to improve flow often failed.

Slide1
Click on box to bring up full size diagram

I’ll be honest that the diagrammatic representation initially confused me and I didn’t quite understand what they were trying to represent. One of the problems is that they are using ‘capacity‘ to describe the needs of patients rather than in its traditional medical sense of how much spare resource there is to respond to a particular need. However what did strike a cord was the 6 reasons they highlighted which caused initiatives to fail.

I have attempted to describe these below. It is important to read the original paper to get a proper understanding but I think the “Just add another form” route to failure will be familiar to many health care professionals (and probably those outside of health care as well!)

Slide4

The authors noted some common themes from interviewees when exploring the absence of consideration of population, capacity or process:

Among the favourite targets of criticism were ‘bed meetings’ that, although intended to produce action on barriers to flow, allegedly produced only talk.

But while there is obvious face validity to the six issues does this help us  or just tell us what we already knew? Thinking that an initiative which works in one location can be easily taken somewhere else should certainly be challenged. And before starting any new project it would seem sensible to make sure everyone understands the population they are dealing with and what that population actually needs.

Sadly on a practical note I am not sure it will help you get your burger any faster though…

What have you learn this week? #WILTW

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Digital Downtime #WILTW

This is the 115th #WILTW

I am currently out of the country on holiday with no phone and an intention to very much ‘look up

A perfect opportunity for a break from What I learnt this Week. But if you are keen for a fix here are some of the most popular posts from 2016 🙂

Let’s consider ‘appropriateness’ inappropriate 

Is your powerpoint slide teaching or are you? 

As calm as you are is as calm as she’ll be

What have you learnt this week? #WILTW

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Surprise: When fear collides with joy #WILTW

This is the 114th #WILTW

Watch young children playing together and you will observe emotions at their most primitive. Intense joy and laughter suddenly replaced by anger when a toy is not given back and utter despair when playtime is over.

I’ve been watching my daughters playing in the unexpected heatwave we had this week in the UK. It was amazing to see emotional gear changes. Moving from low to high at a speed a Tour-de-France yellow  jersey holder would be proud of.

This grid therefore caught my eye this week

Via Vox (click on picture to link to original post)

It’s an intriguing (a mix of disgust and joy) idea and while psychologists might despair (a double dose of sadness) at the over-simplification, for those that have seen Inside Out this really is a very clever representation. Even if you haven’t seen the film (and I suggest you do – I was in tears of both laughter and sadness at various points) there is an obvious face validity to the combination of emotions. The next time you are revulsed by something, stop and think, are you disgusted or afraid?

The grid goes someway to explaining why children sometimes burst into tears when they are surprised and why anger can be such a dreadful core emotion. However it is a shame it misses out on other important core components to our psyche. Where do excitement and curiosity sit? I presume we need a love character to be able to produce passion, shyness and jealousy?

Something to think about the next time you well up with ecstasy, rage or something in between…

What have you learnt this week? #WILTW

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Sepsis and Self-doubt #WILTW

This is the 113th #WITLW

Simon is 18 months old. He has had a cold for a couple of days but on waking his mother finds him to be pale, clingy and not his usual self. He refuses any food and while nestled in his mothers arms appears to become very listless. An ambulance is called and Simon is brought to the Emergency Department. 

He is seen on arrival and noted to be flushed and quiet with a raised respiratory rate (42 breaths per minute) and a high heart rate (165 beats per minute). There is no rash but his hands and feet feel cold. His temperature is 40.1 degrees centigrade. He’d spat out the paracetamol his mother had tried to give him in the morning. 

This child has some  features consistent with being high risk for sepsis. Sepsis is a devastating disease which can rob families of their loved ones in a matter of hours. It makes little differentiation between young and old, and can be as subtle as it is obvious in its presentation. Too often patients are let down because it is not considered, or acted on, promptly.

This week saw the release of the NICE (National Institute for Health and Care Excellence) Sepsis guidance. It is a detailed guide to recognition and initial management, stratified across different age ranges, both in and out of hospital. Families who have lost their children to sepsis , especially those in whom it appears that opportunities were missed to intervene, should welcome the advice it offers. However not treating for sepsis may well be one of the biggest challenges I face in Paediatric Emergency Medicine.

The vast majority of children I see do not have sepsis. It is very important to emphasise that in an era of wide spread vaccination, the rate of serious infection, not even the more serious sequelae of sepsis, in those over 3 months will be less than 7%. Given that febrile illness is the second most common presentation to Emergency Departments (after breathing difficulty) it is easy to see why finding the ‘sepsis’ needle in the ’emergency department’ haystack is an often used phrase.

Needle in haystack

What of Simon and his need for urgent blood tests and antibiotics for his potential sepsis? Simon also has a snotty nose, his throat is red and his ears inflamed. I see in his eyes an awareness of his surroundings. There is a bloody mindedness to the way he tries to push away the paracetamol he is offered and eventually takes. While his peripheries are cool his head and body are very hot and the perfusion of blood to the skin here is normal. While his mother entirely appropriately worries about him,  my instinct is that he does not have a serious infection.

But is my instinct sufficient to fulfil a duty of care to my patients and provide them with the most evidenced based treatment? This is the dilemma I face on an almost daily basis. It is simply not possible to treat all the patients I see who fit some form of criteria as having sepsis. So I remain plagued by self-doubt in my decision making. Will this be the case where I drop the ball and destroy a families life because my gut instinct felt it was just a virus?

My hope it is this self-doubt that keeps patients safe. Guidance like that produced by NICE is essential to provide a framework we can all work to. Awareness raising for professionals and the public like that performed by the UK Sepsis Trust is also vital to ensure knowledge translation occurs at scale. But underpinning everything will be individual health care professionals who must continue to doubt and reflect on their decisions to ensure Simon remains a healthy child and not another preventable tragedy.

Think: Could this be Sepsis? 

What have you learnt this week? #WILTW

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