The High Reliability Emergency Department – Reluctance to Simplify
Posted on January 25, 2013
“The First approach’d the Elephant, And happening to fall against his broad and sturdy side, at once began to bawl: “God bless me! but the Elephant is very like a wall!” – Indian Parable
Last post I focused on how HROs embrace a preoccupation with failure and what that means for those in the emergency department. This post will focus on the next principle on our list which is: Reluctance to Simplify.
This topic highlights both a strength of emergency medicine and reveals a great potential weakness. One strength is caring for patients in that rich, complex gray area of diagnostic uncertainty and need for immediate treatment. However, as we develop more sophisticated “boxes” for patients (Supertracks, STEMI and trauma codes, other protocol-driven care) it becomes easier to over-simplify the patient and their condition.
We must always accept that we (like the blind men in the above parable) base our judgement only on the parts we can “touch” and our past experiences.
HRO PRINCIPLE #2
RELUCTANCE TO SIMPLIFY
Less simplification = Broader Awareness
Viewing the world as complex, unstable, unknowable and unpredictable.
- Welcomes diverse experience and has a skepticism toward received wisdom.
Understands the superficial similarities between the present and past mask deeper differences that could prove fatal.
- Mindfulness – to have a rich awareness of discriminatory detail and enhanced ability to discover and correct errors that could escalate into a crisis.
“Neither Thiokol [contractor] nor NASA expected the rubber O-rings sealing the joints to be touched by hot gases of motor ignition, much less to be partially burned. However, as tests and then flights confirmed damage to the sealing rings, the reaction by both NASA and Thiokol was to increase the amount of damage considered “acceptable.” At no time did management either recommend a redesign of the joint or call for the Shuttle’s grounding until the problem was solved.” Roger’s commission Report on Challenger Accident
On January 28, 1986, 73 seconds after launch the space shuttle Challenger disintegrated causing the deaths of the seven astronauts on board. The failure of an O-ring in its right solid rocker booster set off a rapid chain of events that led to the destruction of the orbiter (Wikipedia – Challenger Explosion). Amongst the many issues that the subsequent investigation revealed were:
- A tendency to simplify problems.
- Failure to appreciate on-going threat that earlier non-fatal failures in the o-rings represented.
- Lack of experienced astronauts in the management of the program (a change from earlier programs).
- Isolation of management at the Johnson Space Program.
- Pressures to launch missions overcoming safety concerns.
Emergency Department Lessons
I think the key aspect for us in the emergency department has to be promoting mindfulness in our daily care of patients. How often have you heard someone say “I knew that was going to happen!” vs. a pre-emptive “Is that patient supposed to look that way?”. Being mindful also includes:
- Actively searching for disconfirming data.
- Overcoming reluctance to express concerns.
- Responding immediately to others’ concerns.
As I said earlier: simplification is a double-edged sword. On the one hand it allows more timely and uniform care of certain medical conditions (cardiac cath for acute MI). However, oversimplification can lead to devastating diagnostic errors.
Frequently physicians cut off exploration of patient’s condition too early.
Use of pattern recognition results in “closest fit” approach.
The results of missed diagnoses include delay in appropriate care.
Classic example is overdiagnosis of gastroenteritis in other serious conditions (appendicitis, etc.)
Healthy skepticism and accounting for all findings help prevent these errors.
I end with a return to communication and how important it is our environment. I have seen many diagnostic misses where someone kept silent for a variety of reasons. I believe that the collaborative wisdom of the care team (nurse, doctor, tech, consultants) is richer than mine alone.
Next week I will be covering HRO Principle #3 (Sensitivity to Operations). The slide set from my original lecture continues to be available at: HRED.