Colloquium at the Human Factors and Ergonomics Society National Conference
Wednesday, 22 September 2004, New Orleans, LA

Even though thorough, objective investigation of medical adverse events is crucial in order to understand their causes, such investigations are exceptional. The complexity of the healthcare environment, litigation, risk and socio-political implications all work to frustrate investigation efforts and reduce the quality of analytical insight. This session will explore the nature and process of medical accidents and their investigation. Participants will examine approaches to the factors that frustrate investigation. During the working portion of the session, individual accidents will be explored and evaluated by the group. The colloquium results will be used as the basis for a whitepaper on the obstacles to medical accident investigation.

Healthcare accidents occur in technical settings that make post-accident investigations difficult to conduct. Work in healthcare facilities is complex and highly variable. The conduct of work depends on deployment of dense professional domain and operational knowledge, much of it arcane and inaccessible to outsiders. Much of the work depends on information that must be pooled and shared across individuals and groups. Irregular conditions are commonplace: emergencies, cancellations, unprepared or absent patients create conditions that change continually.

The environments in which accidents occur have additional traits that make objective, in-depth inquiry difficult. The independence of investigators, varieties of media attention, and potential legal exposures can undermine the depth, breadth, and quality of the investigation process. Organizations that experience adverse events may find it difficult not to treat investigations as threats to institutional integrity. It is common to treat accident events as anomalies, to concentrate on identifying and removing the proximate cause, and to work deliberately to restore normal conditions to the organization. Identification of “operator error” as the “cause” flows, in large part, from the need to reign in post-accident investigations.

Significantly, the inability to respond to accidents with timely, independent, comprehensive accident investigations creates new difficulties for the organization under scrutiny. Local investigations are open to suspicion of complicity in a “cover-up.” Attention from news media can be perceived as eroding confidence in the institution. Continued adverse coverage can lead to diminished support by constituencies that are crucial to its survival. Public consideration of such events can be used as an opportunity to find a scapegoat, “send a message,” or other tactics that run counter to finding out just what happened. Making information public can also be seen as playing into the hands of those who would use it as the basis to discover further facts that could support litigation seeking remedies for losses incurred.

Accident investigation is well developed in other high hazard domains such as air transportation and nuclear power generation. Independent a gencies, e.g. the National Transportation Safety Board (NTSB), engage after-accident situations in ways that build confidence in their ultimate findings. These engagements provide a technically grounded, inclusive, and analytically calibrated examination of accidents. While this approach is the standard for investigation of transportation accidents, health care organizations are deprived of similar resources for investigation of their own adverse events. Each healthcare institution is responsible to develop its own program, using resources at hand. Programs are designed to meet the approval of the accrediting organization when it conducts a review. Investigators who manage such programs may not be technically qualified and can be driven by agendas other than deriving insights and improving healthcare practice.

The Colloquium addressed the situation confronting post-accident investigators and analysts as they grapple with medical accidents. Panel member Yoel Donchin, MD presented a video account of an adverse event involving the unexpected death of a patient in the intensive care unit (ICU). Panel members discussed aspects of the event, its investigation, and analysis. Further contributions from members of the audience identified requirements for the successful performance of such work in healthcare.

References:

Cook, R., Woods, D. and Miller, C. (1998) A Tale of Two Stories: Contrasting Views of Patient Safety. National Health Care Safety Council of the National Patient Safety Foundation. Chicago: American Medical Association.

Nemeth, C. (in press). Healthcare Forensics. In Karwowski, W. and Noy, I. (Eds.).Handbook of Human Factors in Litigation. New York: Taylor and Francis.

Biographies:

Richard Cook, MD, Cognitive Technologies Laboratory

Yoel Donchin, MD , Professor, Hadassah Hebrew University Medical Center , Jerusalem , ISRAEL . E-mail: donchin@cc.huji.ac.il. Dr. Yoel Donchin is a practicing anesthesiologist and serves as the head of the Patient Safety Unit at the Hadassah Hebrew University Medical Center. His current research interests include the study of human error and patient safety. He carries his message about the importance of safety to a general audience by regularly writing for the Israeli newspaper /Haaretz /. He also performs scientific research along with his partners at the "Technion" Israeli Institute of Technology in Haifa. In 1995, this group published the paper on the "Nature and Causes of Human Errors in the ICU" and is currently involved in an in-depth investigation of medical mishaps in Israel. Dr. Donchin uses video as a key aspect of his teaching and accident investigation work and has produced videos entitled "Accident in the Delivery Room" and "The Hazards of Magnesium Administration."

Patricia Ebright, RN, DNS, Assistant Professor, College of Nursing, Indiana University, Clinical Nurse Specialist with expertise in designing delivery-of-care systems. E-mail prebrigh@iupui.edu, Ph (317) 274-7912, Fax (317) 278-1856. Patricia Ebright, DNS, RN, is an Assistant Professor at the Indiana University School of Nursing in Indianapolis, Indiana.  Her current research focus is on increasing understanding of the complexity surrounding acute healthcare environments and how healthcare providers work to create patient safety. After 28 years in acute care settings in staff nurse, manager, and clinical nurse specialist roles, she teaches undergraduate and graduate nursing curriculum.

Christopher Nemeth, PhD, CHFP, Cognitive Technologies Laboratory

Emily S. Patterson, PhD , Ohio State University , 210 Baker Systems, 1971 Neil Ave , Columbus, OH 43210 , Ph: 614-688-3938, Fax 614-292-7852, Email: patterson.150@osu.edu. Emily Patterson received her Ph.D. in Industrial and Systems Engineering from the Ohio State University in December, 2000.  She is currently a Research Physical Scientist and Merit Review Entry Program Awardee (MREP) at the VA Getting at Patient Safety Center (GAPS) in Cincinnati.  She shares Principal Investigator (PI) status on a grant to identify barriers to the adoption of computerized clinical reminders in the VA.  In addition to several health care settings, she has conducted research in space shuttle mission control, an emergency call center, and military intelligence analysis.  She serves as an Advisory Board Member for ECRI’s Health Technology Forecast.  She is lead author on a paper describing the use of the critical incident interview technique to identify human factors themes across five diverse healthcare adverse events.

Michelle Rogers, PhD, VA Cincinnati, Ph: 513-861-3100 ext.5543, E-mail: Michelle.Rogers@med.va.gov. Michelle L. Rogers, Ph.D. is a research scientist for the VA GAPS Center, a position she has held since September, 2001. Since coming to the Center, she has worked on projects involving scenario-based usability testing and cognitive work analysis of the bar coded medication administration and computerized patient record system software for the Department of Veteran Affairs. The GAPS center uses human factors methodologies to identify and design prototypes of software solutions in order to promote patient safety. The Center's focus is on how gaps in continuity of care are bridged by practitioners, and its goal is to create the components of a "safety culture". Her current research focuses primarily on the impact of clinical information systems on the work processes of health care practitioners, with particular interest in the role of technology in patient safety, job design and user centered design.