Preventing Errors in Clinical Practice: A Call for Self-Awareness

Drs. Borrell-Carrio and Epstein certainly present a cogent counterpoint to the prevailing tendency to focus exclusively on systems issues in patient safety. Indeed, the development of self-awareness by individual clinicians and addressing systems issues are likely to be complementary strategies for reducing medical errors. The external conditions that push physicians outside of the optimum work zone can be reduced by addressing systems factors such as interruptions for pages, design of work stations, ability to access clinical information and management of fatigue and workload.

In addition to examining the polar extremes of individual cognition and global systems, a third area of research that can impact patient safety is communication. Recent studies have documented that communication failure is a significant contributor to medical error. (1) Current systems-based strategies to reduce communication failures focus on improving the accuracy and timeliness of the transmission of clinical information through devices such as electronic sign-outs and electronic medical record. These strategies focus on the *content* of communication. However, “communication failure” is often more complex than a simple failure to transmit clinical information. These issues often involve medical hierarchies and ambiguous roles reflecting difficulties in the *process* of communication.

Team training, a strategy borrowed from aviation, has focused on improving team interactions and has been effective in reducing medical errors.(2) But team training has focused more on the acute settings and static team roles. Many clinicians move in and out of multiple “teams” as they move from one care setting to another or from one patient to another. Team training thus far does not translate into improved overall communication skills.

In much the same way as Drs Borrell-Carrio and Epstein are advocating for increased awareness of the physician’s internal cognitive processes, increased awareness of communication processes may also reduce medical errors. “Habits of self-questioning” might also include such questions as:

How might my previous interactions with this other care provider affect my communication now?

What am I assuming in this conversation that might not be true?

What surprised me during this communication? How did I respond?

What interfered with my ability to observe, be attentive or be respectful with the other care provider with whom I am communicating?

How could I be more present and available during this communication?

Were there any points at which I wanted to end the communication early?

If there was relevant information that the other care provider was attempting to transmit to me, did I ignore it?

Medical errors are a significant concern in our health care delivery system. Improvement must include a wide range of targets from the narrow focus of a clinician’s cognition process to the broad-based systems interventions and every process in between including the processes of communication.

1 Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures; an insidious contributor to medical mishaps. Academic Medicine 2004;79:186- 194.

2 Morey JC, Simon R, Jay GD, Wears RL, Salisbury M, Dukes KA, Berns SD. Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the medteams project. Health Services Research 2002;37:1553-81.

Competing interests:   None declared

The article by Borrell-Carrió and Epstein calls on clinicians to be aware of their thought processes, particularly when relying on automatic decision making in the face of incomplete or contradictory information. They suggest that training can improve self-awareness and perhaps reduce some clinical errors through an internal check process. Our error database supports the contention that the processes described in this article lead to errors and harm. One perspective on these errors is to consider these individual acts can be improved through individual provider educational activities. This call is an ancient one: “First, know thyself.” From an alternative systems perspective, this can be viewed as a call to the medical education system to improve its processes and for the creation of individual internal quality improvement feedback loops. Many medical schools are moving in this direction, understanding that teaching people how to think and how to seek answers is more important than imparting “knowledge” in the form of facts. Some post graduate training programs routinely combine self evaluation with external feedback and correction to improve internal performance assessments.

Translating this to error reduction, we agree that the first step towards a safer medical system is for every health care worker to recognize they are both part of the problem and part of the solution. We have repeatedly witnessed this transformation when an individual realizes that routine slips in a system (missing consultants reports, failure to notify patients of normal lab results or missing radiology reports) are errors that will eventually lead to a bad outcome. This recognition typically changes individual behavior, while striving to improve the system. Safety activities based on improving systems and “blame free environments” do not ignore an individual’s contribution to the instigation and perpetuation of errors. These environments use error recognition to improve systems to help people do the right thing, instead of relying on re-education of the individual.

System changes perpetuate safety across multiple individuals and over time, whereas individual educational efforts must be repeated as people are added to the work force or are lucky enough to be identified making an error. In Borrell-Carrió’s scenario, retraining the world’s medical providers to improve self-awareness is a daunting task which would overwhelm available financial and personnel resources. While medical education has proven remarkably difficult to reorganize, if the system can be successfully realigned so that providers will truly “First, know thyself,” then the improvements should be sustainable.

Competing interests:   None declared

8/18/04

To the editor:

We thank Dr. Saba for emphasizing that supervision and reflective exercises can promote self-awareness.

Methods that are used in the moment -- during clinical practice -- have the advantage of creating a habit of questioning that often cannot be accomplished by other means. We believe that Dr. Saba's suggestions are in the right direction. But, our model emphasizes the ability to recognize justifications that practitioners generate when tired, distracted or distressed, which cause them to abandon their better judgment. The goal is to promote a line of defense against what we have called the "failure of heuristics."

It is a small step to apply the strategies that we promote for individual practitioners to group or individual supervision of live, recorded or recalled clinical encounters. However, not all supervisors help trainees recognize points at which errors might have occurred, or specifically identify somatic markers of emotional and cognitive interference in clinical reasoning. We would hope that our approach would help supervisors provide the trainee with tools to avoid the next error. There are many additional ways of fostering mindfulness in action (1-4).

Fortunately, medical educators and researchers have arrived at a new level of sophistication in understanding the inner lives of clinicians. Future research should delineate the specific contributions of each approach; it has become impossible, in a short article, to describe it all.

Sincerely,

Ronald Epstein, MD

Francesc Borrell-Carrio MD

1. Epstein RM, Mindful Practice in Action (II): Cultivating Habits of Mind. Families, Systems and Health 21(1):11-17; 2003.

2. Epstein RM. Mindful Practice. JAMA. 282(9):833-9, 1999.

3. Novack DH, Epstein RM. Paulsen RH. Toward creating physician- healers: fostering medical students' self-awareness, personal growth, and well-being. Academic Medicine. 74(5):516-20, 1999.

4. Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician. Personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient. JAMA. 278(6):502-9, 1997.

Competing interests:   None declared