Infusion Devices
As expected, no one wants to take responsibility. The nurse feels that the anesthesiologist should be responsible. The anesthesiologist on the other hand is convinced that the error has occurred due to the nurses forgetfulness. Such an error, though not directly linked with the system, represents a larger problem in the system. Accidents can provide useful information about a system (Kohl, Corrigan Donaldson 2003, p.51). They represent failures in the system whose breakdown may result in harm. The accident in the case study cannot be understood if contributing factors are isolated and assumed to be the causal factors.
Why Accidents Happen
The infusion device case is a good example of how systems can cause or prevent accidents. A system is defined by Kohn et al (2003, p.52) as a set of interdependent elements interacting to achieve a common aim. Element in this regard are both human and non-human actors. In the case study, the infusion device, the nurse, the anesthesiologist, other medical personnel, their interaction with each other and with the equipment, the procedures, the physical design of the surgical suite where the people and the equipment function constitutes a system. It is recognized that multiple errors that occur together in a kind of interaction not anticipated, igniting a chain of events in which the errors grow and evolve, often result in systems failure (Kohl et al. 2003, p.52).
According to the anesthesiologist, the error was a result of incorrect insertion of the tubing. The nurse is on the other hand convinced that the error is a result of the anesthesiologists failure to adequately check the system before turning on the devices. These are but superficial explanations of the error which are based on hindsight. Both the nurse and the anesthesiologist would not have foreseen the complicated coincidences that resulted in the system failure. It seems obvious to the anesthesiologist that the nurse should insert the tube correctly. The nurse also feels that it should be routine for the anesthesiologist to check the device before conducting any task. These judgments based on hindsight simplify the causes of error or accident since they only explore selected elements as the cause while ignoring multiple contributing factors. As such, it becomes very easy to come up with a simple solution, such as punishing the nurse or anesthesiologist, or both, or to blame each other for the occurrence of the accident, but extremely difficult to determine the actual problem.
This is not to say that the nurse and the anesthesiologist have no role to play in the event of the error. It is acknowledged that the greatest contributor to accidents is human error. According to survey conducted by Perrow (1984), human error contributes to an estimated sixty to eighty percent of accidents (see Kohl et al. 2002, p.53). An assessment of anesthesia suggests that 82 percent of preventable events involved human error. Equipment failure only contributed to the remaining twelve percent of the events. Even when there is equipment failure, it can be aggravated by human error. However, attributing an accident to human error does not mean that we assign blame. There are various reasons why humans commit errors. These reasons may be expected or unexpected.
Various factors may have contributed to the nurses incorrect assembly of the device. The same applies to the failure by the anesthesiologist to check the system before turning it on. Both the nurse and the anesthesiologist committed errors that are by far basic. An error is the failure of a planned sequence of mental or physical activities to achieve its intended outcome when these failures cannot be attributed to chance (Kohl et al. 2003, p. 52). This failure may be a consequence of the greater systemic flaws. For errors to be meaningful, intention must be considered. This is because errors are based on two kinds of failure either actions fail to go as intended or the intended action is not the correct one (p.54). There are possibilities of achieving the desired outcome when actions fail to go as intended. However, there are no possibilities in the second instance. Errors can occur because of slips, lapses or mistakes (Kohl et al. 2003, p.54). Slips and lapses are errors of execution with the difference being that slips can be observed while lapses cannot. Mistakes on the other hand occur when actions go on as planned but fall short of achieving their intended outcome because the planned action is wrong. The situation may arise due to incorrect assessment of the situation or lack of adequate knowledge about the situation.
Lapses, slips and mistakes are all serious errors in medicine since they may harm the patient. The case study shows the seriousness of these errors. In order to assess how the nurse and the anesthesiologist contributed to the error, it is important to differentiate two types of errors active and latent errors. According to Kohl et al (2003, p.55), active errors are those errors that occur at the level of the frontline operator, and their effects are felt almost immediately. Latent errors on the other hand are those that are derived from the operators direct control and encompass things such as poor design, incorrect installation, faulty maintenance, bad management decisions, and poorly structured organizations (Kohl et al. 2003, p.55). The free flow of the medication from the infusion device is the active error in the case study. However, this is not the greatest threat to safety in a complex system since they are easily identified. The greatest threats are posed by latent errors which are mainly unrecognized and may result in multiple kinds of active errors.
Complex and tightly coupled systems are more susceptible to accidents than loose systems. In a complex system, the interaction between a particular component and other multiple components may be unexpected and invisible. Even though various components of systems interact in various multiple ways, there is always a problem when a particular component which serves multiple functions fails. The implication is obvious other dependent functions will fail to operate. The medication administration system in the case study is an example of both complex and tightly coupled system. The simultaneous functioning of the three devices leads to complexity. Tight coupling emerges from the procedures involved in making the system to function properly, assembling the three devices, calculating the correct medication dosage levels, operating the three devices during surgery and responding to the alarms.
Responses to Error
Managers are often advised by ethics researchers to associate rewards and punishment to ethical and unethical behavior respectively (Baucus and Beck-Dudley 2005, p.355). According to Baucus and Beck-Dudley (2005, p.356) an organizations culture, reward and punishment systems, and associated aspects of the organizations design or structure affect the moral reasoning of the employee. There are various stages of moral reasoning. These are heteronomous morality stage which involves doing the right thing only for the sake of avoiding punishment individualism stage where individuals do right to serve their own needs or interests a stage where people doing right because it is demanded by law and because obedience to it is necessary to uphold social institutions people respecting minority rights and beliefs and individuals having universal set of principles and strong personal commitments to following them (Baucus and Beck-Dudley 2005, p.357).
A virtue culture results in a formation of an ethical staff. It increases employee participation in decision making which further contributes to an ethical community. By allowing the employee to participate in decision making, they gain greater control over their work. A culture that enables employees to make decisions concerning their work, such as assembling machinery, makes it possible for the employee to contribute to how a given procedure may be made less harmful. In the case study, adopting a virtue culture could have led to consultation by the nurse on how to assemble that particular type of infusion device.
Many organizations that seek to minimize error also increase their compliance system. Within the compliance culture, organizations adopt formal mechanisms such as codes of conducts, compliance or ethics officers, and reporting hotlines to identify errors and punish those responsible. The standard response for an organization with compliance culture is increasing or stiffening rules or control system to prevent the recurrence or error. One response in the case study may involve additional strict rules in the assembly and use of the infusion device.
It is thus clear that the events in the case study may be different depending on whether the system adopts a compliance culture or virtue culture.
Changing System Root Cause Analysis
The best method of responding to incidents is by reporting the facts and then taking systematic measures to prevent the reoccurrence of the same event. Performing a root cause analysis is an appropriate response to such serious events. Root cause analysis is a very comprehensive systems-based response to a serious event designed to identify actions that can improve the patients safety and minimizing the risk for the organization.
Root cause analysis is very important in finding the actual causes and manifestation of errors. A thorough root cause analysis should lead to recommendations that improve the overall safety of the system. It is an important mechanism for introducing healthcare professionals to systems thinking, for changing individual behavior, and establishing a culture of safety (Carroll et al., 2002 in Runciman, Merry Walton 2007, p.217).
Using the Root Cause Analysis framework, a thorough assessment can be conducted using a multidisciplinary team. The team approach has the advantage of teaching and a thorough analysis of latent factors within the organization. In the case study, the team should be composed of the anesthetist, a pharmacist, a nurse from the holding area, an operating room manager and a surgeon. The facilitator, who is also responsible for the training of the team, should be an individual who has received formal training in Root Cause Analysis (Rucinman, Alan Walton, Merrilyn 2007, p.207).
Conducting RCA on the Case Study
The first step in conducting a root cause analysis on the case is to review the medical records, hospital policy documents, incident form and letters from the patient and the health professionals involved in the incident. Once the problem is defined, the second step is to write a clear statement of the problem. Root causes or contributory factors are to be identified. Finally, root cause statements are to be developed.
Leadership and Culture of Safety
From the analysis of the case study, it is clear that instances of error can be greatly minimized by improving performance. However, this is just one aspect of establishing a culture of safety. How the organization responds to error is another important aspect. In most cases, the response involves a combination of cover-ups, denial and stonewalling (Leape 2007, p.64). In most cases, the patient is not always aware of the error. In the case study, no one took the responsibility to explain to the patient that the increase in her temperature was a result of an error in the hospitals system and not the result of the sickness. The usual response by the hospital is to stop anything from leaking out to the public by all means possible, and this implies holding the information from the patient and her family.
Patients who have been victims of errors are content with complete and honest account of what actually took place (Leape 2007, p.64). They also want the people who are responsible to apologize and assure them that the same problem will not reoccur. In short, they need full disclosure. A full disclosure policy in an organization makes it easier for the staff to be honest with patients. How this is done is also very important. However, full disclosure is not simple for the physicians. On the contrary, some doctors feel that demanding for full disclosure is punishment to the physician (Leape 2007, p.64). It is difficult to tell the patient in the case study that she could have died of an overdose because of a mistake in assembling the infusion device. A full disclosure policy should not place the burden on the physicians. The organization also shares the responsibility since errors mirror defects in the system and not simple human mistakes.
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