Distraction

Distraction

In a previous post (http://www.medicallaboratoryquality.com/2014/02/validation-verification-and-vindication.html) I mentioned an observation reported in the Harvard Business Review about 47 percent of people regularly having a wandering mind.  The point was made that distraction is a very common cause of work related error. 

This raises in my mind a variety of interesting avenues, such as, if half of people working in your laboratory are intermittently or regularly distracted, how do we ever get anything done on time and right the first time.  Crosby’s DIRFT must be an impossible dream.  

Well in some respects I think there is some truth here, but we are protected from most disasters because of our own systemic ingenuity and maybe a lot of luck.  James Reason of “Error Fame” points to what some call the Swiss cheese barriers that block most bad events from manifesting.  

We pick up on clues that tell us that what is about to happen is nonsense or wrong.  The name or check mark is not present, the color or shape is wrong, the whistle is blowing.  Something alerts us that something needs fixing.  His point is that for most inadvertent errors to occur you have to experience the uncommon (not uncommon enough!) combination of bad timing, wrong circumstance, bad luck, and absolute obliviousness.  Most causes get stopped; very few work their way through to an outcome or effect.  

But I turned to a book by Edward Hallowell, who writes on attention deficit disorder to see if he had any suggestions that might help the 95 percent of us that do not have ADD, but nonetheless have episodes of distraction that could mess things us. 

So in the spirit of Culture of Quality improvement and Distraction Abatement and Error Avoidance in the medical laboratory and with thanks to Edward Hallowell and John Ratey, I offer the following:

• ·       Both excess quiet and excess noise make a laboratory a not nice place to work.  Often you hear people say they don’t hear all those cabinet fans and motors anymore, but they are wrong.  They do hear them and they drive your staff crazy.  Background music can be a problem because of the wide variety of personal choice.  Some folks actually can work better with a personal headset and an iPod.  Don’t be afraid to give it a try.

• ·       We are all visual beings.  Bright colour is a good thing.  There is no reason that all laboratories have to be monochromatic white or cream or grey.

 

• ·       If your technologists need to regularly work through computer screens, get rid of those old green/white or black/white eye sore monitors and make sure the software screens have enough pizazz to capture your staff’s interest and attention.

• ·       Provide for lunch and learn open-talk sessions on strategies that help reduce distraction and error.

• ·       Encourage staff to take a regular break, even for a few moments when they have been sitting at their bench for more than 30 minutes.  They should stop doing what you are doing, stand-up, stretch and breathe.  Then start again. 

• ·       To the extent possible, require people to take their mid-morning and mid-afternoon and lunch breaks and use it for want they were intended. In my son’s work-site people have access to ping pong, to exercise equipment, to music, or to just sitting or taking a walk.  I haven’t seen than in many laboratories (although lots of places have group exercise) but that would be wonderful.  Note to laboratory managers, spend a little money and make sure that your staff has some comfortable chairs and sofas in their break room. 

• ·       Enough with those conference chairs!!

Validation Verification and Vindication

Validation Verification and Vindication

We live in an era that loves to believe in logic and discipline as the basis of progress.  In near every discipline the clarion call to quality is that decisions must be evidence-based.  Evidence-based medicine is touted as the foundation for all diagnosis, investigation and treatment, based on the assumption that the overwhelming mass of studies performed and published provides us with all the information that we need.  

But it is pretty clear that many (most ?) of those studies are too small, too uncontrolled, and too biased and essentially not reliable, but we can do our best by combining studies and through meta-analysis can make the proverbial silk purse.  Despite this we generate tons of confusing and contradictory guidance in most things that are important, such as nutrition, vitamin usage, cardiac risk and anti-lipid therapy, and exercise, and on and on.  

For an interesting read on this subject, today I found an editorial in the Saudi Gazette written by Gary Taubes of the New York Times in which he talks about the “field of sort-of-science” in which “hypothesis is treated as facts”.   

The problem is not that we suffer from insufficient data or insufficient tools; indeed we live in the era of Big Data Analysis where thousands of databases with billions (and trillions) of points are available for picking and mining.  No it is not a problem of insufficient data; rather it is a problem of dirty data, poorly defined, incomplete, improperly gathered, and all too often inappropriately or insufficiently analyzed. 

Ultimately the problem is that we are left with the same lingering question “Who do you trust?”

To get on top of the solution we think in terms of Verification (is the analyzer capable of providing a repeatedly reproducible result within a narrow range of allowable error?) or Validation (do test results provide a result that is consistent with the gold standard and can they distinguish groups of subjects who are consistently “positive” from those that are consistently “negative” as measured by other parameters?).

But in addition I argue that we even more heavily rely on Vindication, which in this context I use to mean, “My approach must be right because I came to the same conclusion as noted in this other study”.  It’s a pretty soft measure, and a throwback to “evidence by authority” which predominated in the Dark Ages.  But it does have its compelling aspects.

 

I will give you an example.  In the Winter 2013 edition of Harvard Business Review Edward Hallowell wrote an article about a study published by Gilbert and Killingsworth in Science (Nov 2010) about people’s ability to focus on what they are doing and their sense of happiness.  What the study pointed out was that based on a pool of 2200 adults and over 250,000 observations, about 46 percent of people will commonly have their minds wander, even if they are enjoying what they are doing.  Hallowell, a psychiatrist and prolific writer on the subject of distraction writes, “Not only does such a lack of focus lead to unhappiness, it results in errors, wasted time, miscommunication, and misunderstanding, diminished productivity, and who knows how much global loss of income…”   

Now I am not a psychiatrist  (although I did a huge wack of training in psychiatry in my younger years), but in that sentence Hallowell summarizes the singular challenge for medical laboratory, and indeed all, Quality.  Recognizing that distraction occurs regularly is totally consistent with James Reason’s views on human error (slips and mistakes) and is consistent with Decker’s views on response to error, and is consistent with non-linearity of cause and effect in Chaos theory.   Lots of people (maybe most? maybe all?) lose concentration during work, and when that happens the opportunities for error and confusion arise.   Telling people to try harder is not an answer.  Telling people to Do it Right the First Time, is not an answer either.

Putting in systems to prevent the consequences of inattention and distraction (think Lean Poka Yoke) and putting in systems that will pick up on errors as early as possible, and putting in systems to reduce the repeating of error have a far more reasonable likelihood of success. 

I understand that my buying-in to this hypothesis is exactly what Taubes (sort-of-science) was concerned about (hypothesis becoming fact).  He would say that the linkage between distraction and error remains unproven.  But I have to say, without apology, that it works for me and I believe it.

Vindication.

Transcription errors can maim and kill

I have said on a number of occasions that we run a microbiology proficiency testing program that is predicated on the use of simulation as a learning and challenging process.  If our samples look and act like real samples, then laboratories can use them in a variety of ways to improve process.  A recent survey indicates that we get a lot of support from our participants because of our simulation potential (more on this later).  

But there is one situation in which we do not get a lot of support; indeed some folks get really angry.  We have a committee philosophy and policy that says that our samples have identification with two identifiers and we consider that as the sample’s name.  If a sample is not designated by its proper name, regardless of the work performed, the sample fails.   This genuinely upsets some of the laboratories because they see this as unfair and unreasonable.  

With respect, I disagree.  We refer to improper naming of samples or indeed any incorrect submission of  forms as a post-examination error.  And we take a very aggressive attitude towards post-examination error.

Jump to yesterday’s National Post, one of Canada’s most prestigious national newspapers.  With disappointment we read the story of 4 women who were severely harmed and indeed maimed by the healthcare industry because someone put the wrong breast biopsy report on the wrong patient’s chart, resulting in the wrong person getting the wrong surgery.  In another mix-up the wrong patient ended up with a diagnostic biopsy and the other patient received delayed care because two samples that came to the laboratory got mixed up in accessioning.

One politician’s response, “We are sooo sorry“, and another was “Well, healthcare is run by people and sometimes people make mistakes”.  Another response, “Well, we were planning to put in a bar-code system that will reduce the chance of this happening again”.

Look, I have read James Reason and his books on risk and error, and I get it, sometimes people screw up;  sometimes we call them slips, sometimes we can them distractions, and sometimes we call them mistakes.  Most of the time, they are invisible or they cause at most some inconvenience.  But sometimes they don’t.  Sometime, especially in healthcare, they can hurt people.  In some industries fail-safe check systems are introduced to prevent them from happening at critical times.  In some industries they talk about fail-safe, and in others they don’t even bother talking about them.  

In the past I have talked about the casualness that exists in healthcare when it comes to post-examination error, in particular when it affects confidentiality.  [see: http://www.medicallaboratoryquality.com/2013/08/confidentiality-and-laboratory-error.html ]  If we just accept slips to occur without acknowledging their consequences, then we allow folks to not worry about them.  And that can lead to really bad outcomes.

And at that point, the problem is no longer slips and inattention, it is failure to develop policies and processes to protect patients.

So CMPT will continue to consider transcription errors as part of the proficiency testing exercise and will continue to view them as Major Errors.  

And so should you.

PS:

Our POLQM Quality Conference is coming along really well.  Hope to see you in Vancouver.  If you come, let me know that you are a sometimes reader of MMLQR.

http://polqm.ca/conference_2013/conference_2013/conference_home.html