The application of the above concepts of performance and error to patient care is hampered by disagreements over whether human error is distinct from human performance.58,59,75 It has been argued (1) that assignment of error is often retrospective and subject to hindsight bias and (2) that the term error is inherently prejudicial, retarding rather than advancing understanding of system failure and tending to evoke defensiveness from physicians rather than constructive action.59These arguments notwithstanding, elimination of human errors is clearly an impossible goal: a more realistic goal is to understand what causes errors and to minimize or, if possible, eliminate their consequences.
There is also some disagreement about the applicability of these concepts (which derive from analysis of well-structured, well-understood technical systems) to the more complex issues of patient safety and quality of care.61 Besides the possible relationships already suggested, the concepts of performance and error can in fact be explicitly linked with two widely accepted quality-of-care paradigms. In the IOM paradigm, inappropriate care is categorized as attributable to overuse, misuse, or under-use.76 Overuse is triggered by mistakes (sometimes rule-based but more often knowledge-based) but rarely, if ever, by slips or lapses. Underuse is triggered by mistakes or lapses, but not by slips. Misuse is caused by all three kinds of errors.77 In the Donabedian paradigm, quality is framed in terms of structure, process, and outcome.78 Faulty processes do not always result in adverse outcomes, but considering the process of care is as important as considering the outcome.
Regardless of which psychological construct of performance and error one may subscribe to, there is substantial evidence that performance is affected by the context of the problem. The main elements that define context are knowledge factors, attentional dynamics, and strategic factors.25 The first two elements are self-explanatory. Strategic factors include an individual's physical and psychological well-being, and in this regard, the effects of sleep deprivation and fatigue on performance and learning are major concerns.79,80 Fatigue, by impairing vigilance, can accentuate confirmation bias. In addition, errors increase as time on task increases; no other hazardous industry permits, let alone requires, employees to regularly work the long hours common in hospitals.74 Stress may increase the likelihood of error, but it is clearly neither necessary nor sufficient for cognitive failure.60 Unfortunately, some physicians hold unrealistic beliefs about their ability to deal with stress and fatigue and so may not seek help when they need it.81
In situations involving a plethora of tasks, mental overload may compromise the ability to respond to secondary tasks. Errors related to loss of vigilance include not observing a data stream at all, not observing a data stream frequently enough, and not observing the optimal data stream for the existing situation. Although vigilance is essential, even vigilant practitioners may experience failures of observation that lead to adverse events. In watching for rare occurrences, it is difficult to remain alert for longer than 10 to 20 minutes; thus, knowing when and how to verify data is an important metacognitive skill.
Psychological framing effects also play a role in error. Examples of such effects are the irrational preference for established treatments when outcomes are framed in terms of gain (e.g., survival) and the similarly irrational preference for risky treatments when outcomes are framed in terms of loss (e.g., mortality). The impetus to "do the right thing" can facilitate error.62
Patient care often involves team behavior, and such behavior can affect individual performance.5'74 Lack of cohesion and mutual support among team members can compromise performance. Too informal a team structure may undermine patterns of authority and responsibility and hinder effective decision-making. Conversely, too strong a hierarchy may make it excessively difficult for juniors to question decisions made by those at higher levels of authority. Rigid behavior may impair the ability to cope with unforeseen events and discourage initiative.
For good teamwork, it is essential that team members share a clear understanding of what is happening and what should happen. This understanding is referred to as situational awareness.74 Unfortunately, there is a common tendency to believe that the prevailing level of situational awareness is higher than it is. For example, the aviation industry improved its safety record when it identified and removed barriers impeding junior officers from communicating with the captain, and these improvements occurred after good communication was already thought to exist.82
In the OR, teams consist of crews from nursing, surgery, and anesthesia. As an example of suboptimal situational awareness, the various crews often have fundamentally different perceptions of their respective roles. Anesthesiologists and nurse anesthetists are much more likely to feel that a preoperative briefing is important for team effectiveness than surgeons and surgical nurses are, whereas surgeons and surgical nurses are more likely to feel that junior team members should not question the decisions of senior staff members.83 Such varying perceptions not only can compromise patient safety but also represent lost opportunities for teaching or learning. Unfortunately, there is often little consensus on how optimal team coordination should be achieved.
The importance of teamwork issues in the OR is illustrated by a study that analyzed time needed to learn minimally invasive cardiac surgery.84 On the fast-learning teams, the members had worked well together in the past, they went through the early learning phase together before adding new members, they scheduled several of the new procedures close together, they discussed each case in detail beforehand and afterward, and they carefully tracked results. Of particular interest was that surgeons on the fast-learning teams were less experienced than those on the slow-learning teams but more willing to accept input from the rest of the team.
Communication and teamwork are also important in the emergency department. One study reported an average of 8.8 teamwork failures per malpractice incident, with more than half of the deaths and permanent disabilities judged to be avoidable.85
The key message is that errors frequently are a product of the context in which they occur. It is tempting to assume that a few "bad apples" are responsible for most safety and quality problems. In reality, however, bad apples are relatively few, and they account for only a small percentage of medical errors. To achieve significant overall improvements in quality, all physicians will have to make efforts to improve the context in which patient care is delivered. In addition, nonphysicans will have important roles to play, as illustrated by studies relating nurse staffing levels to quality of care.86,87
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