Despite the education and dedication of healthcare professionals,1 undesired patient outcomes can occur. Patient safety events in Pennsylvania involving temporary or permanent harm or death were presented in the previous issue of the Pennsylvania Patient Safety Advisory, in an article titled "Are You Ready to Respond? Reports of High Harm Complications after Surgery and Invasive Procedures."2 High harm events are devastating for patients, families, and care providers and may be even more distressing if human errors contributed to the event.3 Because some events of patient harm involve human error, some people may question whether humans are the problem, the weak link in our efforts to provide safe healthcare.
In their efforts to prevent the recurrence of events involving patient harm, healthcare facilities have implemented learning processes such as root cause analyses (RCAs). Contemporary RCAs seek to deconstruct patient safety events to identify one or more known or previously unrecognized threats to patient safety that aligned to allow errors or harm to occur.4,5
Advances in understanding the multifactorial etiology of harm, such as James Reason's "Swiss cheese model," search for failures proximal to the final act of commission or omission in the belief that a combination of factors contributes to an event in which a patient is harmed.5 These factors may arise suddenly, or may be "latent safety threats" that were introduced in time periods long before the harm event and then coalesced with unintended consequences.5
Although the Swiss cheese model expands our analysis beyond the final act by a provider at the "sharp end," this perspective is still often limited to seeking discrete points of failure without recognizing the impact of interactions between components or the dynamic contributions of the healthcare environment.6,7 Knowing how each part of the healthcare delivery system works—at a sequential or interdependent level—is important, but it will not necessarily provide us with an understanding of how the system works as a whole.
As an (albeit limited) example, specific parts of a car need to work in order to drive—the engine, the brakes, the steering assembly, and so on. Nevertheless, having a mechanically functional car does not ensure that drivers will arrive safely at their intended destination. Many factors can impact a driver's success, including their own driving skill, road conditions, weather, and the skill of other drivers. Although drivers may intend to drive smoothly from their starting point to their endpoint, they inevitably make unanticipated adjustments along the way.
Although some healthcare delivery activities can appropriately be reduced to linear, sequential processes, other activities are interdependent, and some are complex adaptive processes that interact with and impact each other. Healthcare professionals must negotiate systems and balance choices much more complex than driving from point A to point B. In some circumstances, regulations and rigid protocols that restrict the options for provider actions are necessary and appropriate. In other circumstances, adaptability, resourcefulness, and even creativity are important.8 Healthcare delivery is a complex adaptive system with interactions and consequences that may not be completely predictable or even knowable.9
To paraphrase a principle often attributed to James Reason, patient harm is infinitely creative. Evidence-based-practice principles provide important guidance but may not completely address the specific or unexpected circumstances of an individual patient. Healthcare professionals may need to solve problems for which there is no completely suitable, evidence-based process, such as when the preferred medication is unavailable because of a drug shortage, or when a new pattern of antibiotic resistance emerges, or when a patient exhibits a unique combination of medical conditions or injuries.
The National Academy of Medicine asserts that "people working in health care are among the most educated and dedicated work force in any industry."1 Humans sense-make, they find patterns in chaos and assign meaning to ambiguous data, which can occur only through human reflection.10 Humans solve problems,11 learn, invent, anticipate,12 create, and make decisions. They are the thinking part of the man-machine team.11
Skilled, thoughtful, perceptive, and yes, imperfect, healthcare professionals must sort through the onslaught of new information, emerging technologies, competition for resources, ever-increasing societal expectations, and the personal preferences of individual patients to craft the safest healthcare delivery. Humans, regrettably, can create problems, but they also innovate and create ingenious solutions.
Encouraging humans to be adaptable improves their skill at navigating complexity, solving problems, and ultimately, improving patient safety. The ability of humans to solve problems and their capacity for compassion are invaluable resources. Humans can be part of healthcare delivery problems, but they are also essential and irreplaceable contributors to solutions.
- Institute of Medicine Committee on Quality of Health Care in America. Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington (DC): National Academy Press; 1999 Nov. 223 p. Also available: https://www.nap.edu/read/9728/chapter/1.
- Are you ready to respond? Reports of high harm complications after surgery and invasive procedures. Pa Patient Saf Advis. 2018 Dec;15(4). Also available: http://patientsafety.pa.gov/ADVISORIES/Pages/201812_HighHarm.aspx.
- Ullström S, Andreen Sachs M, Hansson J, Øvretveit J, Brommels M. Suffering in silence: a qualitative study of second victims of adverse events. BMJ Qual Saf. 2014 Apr;23(4):325-31. Also available: http://dx.doi.org/10.1136/bmjqs-2013-002035. PMID: 24239992.
- RCA2: improving root cause analyses and actions to prevent harm. [internet]. Boston (MA): Institute for Healthcare Improvement (IHI); 2015 Jun 16 [accessed 2018 Jan 26]. Available: http://www.npsf.org/?page=rca2.
- Reason J. Managing the risks of organizational accidents. Aldershof (UK): Ashgate Publishing Limited; 1997.
- Hollnagel E, Wears RL, Braithwaite J. From Safety-I to Safety-II: a white paper. University of Southern Denmark; University of Florida; 2015. 43 p.
- Leveson NG. Rasmussen's legacy: a paradigm change in engineering for safety. Appl Ergon. 2017 Mar;59(Pt B):581-91. Also available: http://dx.doi.org/10.1016/j.apergo.2016.01.015. PMID: 26860739.
- Vincent C, Amalberti R. Safer healthcare: strategies for the real world. Springer Open; 2016.
- Deutsch ES. More than complicated, healthcare delivery is complex, adaptive, and evolving. Pa Patient Saf Advis. 2016 Mar;13(1):39-40. Also available: http://patientsafety.pa.gov/ADVISORIES/Pages/201603_39.aspx.
- Battles JB, Dixon NM, Borotkanics RJ, Rabin-Fastmen B, Kaplan HS. Sensemaking of patient safety risks and hazards. Health Serv Res. 2006 Aug;41(4 Pt 2):1555-75. Also available: http://dx.doi.org/10.1111/j.1475-6773.2006.00565.x. PMID: 16898979.
- Swenson LS Jr, Grimwood JM, Alexander CC. This new ocean: a history of Project Mercury [NASA SP-4201]. Washington (DC): National Aeronautics and Space Administration (NASA); 1989. An American in orbit. Also available: https://history.nasa.gov/SP-4201/ch13-4.htm.
- Endsley MR. Toward a theory of situation awareness in dynamic systems. Hum Factors. 1995;37(1):32-64.