“Sarah, can you hear me?”
The patient lies on the trolley, silent and grey. The doctor bends over her with growing concern. Now he feels no pulse, no breathing – and a once innocuous situation has slipped into crisis. Professional instinct takes over: with a pull of a lever, the bed slams flat for CPR; the room fills with figures rushing for syringes, drugs, tubes; the registrar places both hands over the sternum, lifts them up and… starts laughing.
“Er, how do I do this again?”
I’m standing in Imperial College London’s simulation suite at St Mary’s Hospital, London. We are filming for the upcoming “You Are The Doctor” session on medical decision-making at the BX2015 conference. The idea behind the session is to show how easily medical errors can happen, and what we can do to prevent them. Participants will watch a series of films and actually be able to vote in real-time about which decisions to take, and then see how they turn out. We think this is the first time something like this has been tried.
There are good reasons to study medical decision making. Errors can affect any stage of care, including diagnosis, treatment, and discharge. One estimate is that 8% to 12% of acute hospital admissions result in an adverse event that could have been prevented. Behavioural science can add to existing “human factors” work by showing how our mental shortcuts, which often serve patients and practitioners well, can also cause errors: one study found that “cognitive factors” contributed to 74% of the harmful incidents assessed.
However, it’s important to stress that the behavioural sciences recognise that whether mental shortcuts help or harm depends on how well they fit with the decision maker’s particular environment. Rules of thumb that work well in one place may not work well in another. Therefore, it is important not to focus blame for errors on individuals, but rather assess how the way that healthcare systems are set up invites errors when people interact with them. Doing so can then suggest how changes can be made to the care environment so that people’s natural reactions result in safe practices. For example, many of the advances in hand washing practices have looked at how placing simple prompts in the care environment can lead to people forming new, sustainable habits.
Not so long ago, an influential book warned people designing policies and systems to “expect error”. We hope we have created films that will open people’s eyes to how easily errors can occur, and how we cannot afford to design them into our healthcare system. Our goal is to find simple ways to make it as easy as possible for practitioners to get it right first time.