Chilling stuff, and a lot of this is probably Whites doing it. Throw some diversity in and healthcare becomes a death trap.
Many serious medical errors result from violations of recognized standards of practice. Over time, even egregious violations of standards of practice may become “normalized” in healthcare delivery systems. This article describes what leads to this normalization and explains why flagrant practice deviations can persist for years, despite the importance of the standards at issue.
Over the last decade, hospital safety personnel have gradually become disabused of a long-standing but incorrect belief: that harm-causing medical errors, such as wrong-side surgeries or retained surgical instruments, result from a single individual doing something inexplicably stupid. Rather, contemporary research on mega disasters—for instance, Chernobyl, space shuttles Challenger and Columbia, Bhopal, and any number of patient care catastrophes—has consistently shown that major accidents require (1) multiple people (2) committing multiple, often seemingly innocuous, mistakes that (3) breach an organization’s fail-safe mechanisms, defenses, or safety nets, resulting in (4) serious harm or frank disaster. In other words, mistakes such as failing to check or record a lab finding, ordering the wrong drug, or entering a lab finding in the wrong patient’s chart are usually not enough to guarantee an occurrence of harm. The recipe for disaster additionally requires these errors, lapses, or mistakes* to go unattended, unappreciated, or unresolved for an extended period of time*. Harm-causing errors therefore result from “active errors” intermingling with “latent errors”: laws or weaknesses in a system’s defenses that allow the former to breach those defenses, reach patients, and cause harm.
[...]
Example #1: A study recently conducted by the group VitalSmarts and the American Association of Critical Care Nurses revealed that common rule-breaking practices in American hospitals include: not washing or sanitizing hands sufficiently; not gowning up or skipping some other infection-control procedures; not changing gloves when appropriate; failing to check armbands; not performing safety checks; using abbreviations; not getting required approval before acting; and violating policies on storing or dispensing medications. Note the difference between these actions and performing a wrong-side surgery or administering a 10-fold overdose of medication to a patient.
Example #2: A classic article about a patient who was mistaken for another patient, and began receiving that patient’s procedure, noted that the subsequent investigation of this “wrong patient” case uncovered 17 distinct errors: “The most remediable of these were absent or misused protocols for patient identification and informed consent, systematically faulty exchange of information among caregivers, and poorly functioning teams.”
Example #3: A case related to the author by a physician nicely illustrates how deviations become normalized:
When I was a third-year medical student, I was observing what turned into a very difficult surgery. About 2 hours into it and after experiencing a series of frustrations, the surgeon inadvertently touched the tip of the instrument he was using to his plastic face mask. Instead of his requesting or being offered a sterile replacement, he just froze for a few seconds while everyone else in the operating room stared at him. The surgeon then continued operating. Five minutes later he did it again and still no one did anything. I was very puzzled, but when I asked one of the nurses about it after the operation, she said, “Oh, no big deal. We’ll just load the patient with antibiotics and he’ll do fine.” And, in fact, that is what happened; the patient recovered nicely.
Example #4: A catastrophic negligence case that the author participated in as an expert witness involved an anesthesiologist’s turning off a ventilator at the request of a surgeon who wanted to take an x-ray of the patient’s abdomen (Banja, 2005, pp. 87-101). The ventilator was to be off for only a few seconds, but the anesthesiologist forgot to turn it back on, or thought he turned it back on but had not. The patient was without oxygen for a long enough time to cause her to experience global anoxia, which plunged her into a vegetative state. She never recovered, was disconnected from artificial ventilation 9 days later, and then died 2 days after that. It was later discovered that the anesthesia alarms and monitoring equipment in the operating room had been deliberately programmed to a “suspend indefinite” mode such that the anesthesiologist was not alerted to the ventilator problem. Tragically, the very instrumentality that was in place to prevent such a horror was disabled, possibly because the operating room staff found the constant beeping irritating and annoying.
Chilling stuff, and a lot of this is probably Whites doing it. Throw some diversity in and healthcare becomes a death trap.
> Many serious medical errors result from violations of recognized standards of practice. Over time, even egregious violations of standards of practice may become “normalized” in healthcare delivery systems. This article describes what leads to this normalization and explains why flagrant practice deviations can persist for years, despite the importance of the standards at issue.
>
> Over the last decade, hospital safety personnel have gradually become disabused of a long-standing but incorrect belief: that harm-causing medical errors, such as wrong-side surgeries or retained surgical instruments, result from a single individual doing something inexplicably stupid. Rather, contemporary research on mega disasters—for instance, Chernobyl, space shuttles Challenger and Columbia, Bhopal, and any number of patient care catastrophes—has consistently shown that major accidents require (1) multiple people (2) committing multiple, often seemingly innocuous, mistakes that (3) breach an organization’s fail-safe mechanisms, defenses, or safety nets, resulting in (4) serious harm or frank disaster. In other words, mistakes such as failing to check or record a lab finding, ordering the wrong drug, or entering a lab finding in the wrong patient’s chart are usually not enough to guarantee an occurrence of harm. The recipe for disaster additionally requires these errors, lapses, or mistakes* to go unattended, unappreciated, or unresolved for an extended period of time*. Harm-causing errors therefore result from “active errors” intermingling with “latent errors”: laws or weaknesses in a system’s defenses that allow the former to breach those defenses, reach patients, and cause harm.
> [...]
> Example #1: A study recently conducted by the group VitalSmarts and the American Association of Critical Care Nurses revealed that common rule-breaking practices in American hospitals include: not washing or sanitizing hands sufficiently; not gowning up or skipping some other infection-control procedures; not changing gloves when appropriate; failing to check armbands; not performing safety checks; using abbreviations; not getting required approval before acting; and violating policies on storing or dispensing medications. Note the difference between these actions and performing a wrong-side surgery or administering a 10-fold overdose of medication to a patient.
>
> Example #2: A classic article about a patient who was mistaken for another patient, and began receiving that patient’s procedure, noted that the subsequent investigation of this “wrong patient” case uncovered 17 distinct errors: “The most remediable of these were absent or misused protocols for patient identification and informed consent, systematically faulty exchange of information among caregivers, and poorly functioning teams.”
>
> Example #3: A case related to the author by a physician nicely illustrates how deviations become normalized:
>
> When I was a third-year medical student, I was observing what turned into a very difficult surgery. About 2 hours into it and after experiencing a series of frustrations, the surgeon inadvertently touched the tip of the instrument he was using to his plastic face mask. Instead of his requesting or being offered a sterile replacement, he just froze for a few seconds while everyone else in the operating room stared at him. The surgeon then continued operating. Five minutes later he did it again and still no one did anything. I was very puzzled, but when I asked one of the nurses about it after the operation, she said, “Oh, no big deal. We’ll just load the patient with antibiotics and he’ll do fine.” And, in fact, that is what happened; the patient recovered nicely.
>
> Example #4: A catastrophic negligence case that the author participated in as an expert witness involved an anesthesiologist’s turning off a ventilator at the request of a surgeon who wanted to take an x-ray of the patient’s abdomen (Banja, 2005, pp. 87-101). The ventilator was to be off for only a few seconds, but the anesthesiologist forgot to turn it back on, or thought he turned it back on but had not. The patient was without oxygen for a long enough time to cause her to experience global anoxia, which plunged her into a vegetative state. She never recovered, was disconnected from artificial ventilation 9 days later, and then died 2 days after that. It was later discovered that the anesthesia alarms and monitoring equipment in the operating room had been deliberately programmed to a “suspend indefinite” mode such that the anesthesiologist was not alerted to the ventilator problem. Tragically, the very instrumentality that was in place to prevent such a horror was disabled, possibly because the operating room staff found the constant beeping irritating and annoying.
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