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First Victim and Second Victim: Patient Safety and Justice

Posted by Sidney Dekker on Wednesday September 4th, 2013

Judging from what has been written, conferred about, said and proclaimed over the past two decades, healthcare shows much interest in its first and second victims. But it doesn’t show as much practical progress. “First” victims of adverse events are typically patients; “second” victims are the providers involved in such an event that (potentially) harms or kills a first victim, and for which they feel personally responsible. So why the lack of progress?

 Cook, Amalberti and other authors in the field point to the huge obstacles that healthcare faces. The complexity and heterogeneity of the field, the low and thus relative invisibility of its body count (at any one institution), the actor autonomy of many of its top practitioners, the haphazard bricolage behind the creation of some of its key technologies, and the uncertainty and emergent nature of its core knowledge.

 So let me, for this blog, briefly pause to look at some of the historical-institutional reasons for a lack of progress.

 Hospitals were designed for a time when care was far simpler. Today we have at least twenty times more prescription drugs but essentially the same prescription methods (except for a bit of technological candy-wrapping) as a few decades back. Healthcare has more technology in general—much more—than before, but a lack of systematic human factors/usability testing and certification, a lack of integration, and a lack of education or “checking out” practitioners on new pieces of kit.

 Having flown airliners on the side while I was a professor in Sweden, to me these are quite vexing aspects of healthcare. They seem to confirm many of Amalberti’s suspicions about the continued valorization of actor autonomy and craftsmanship. In addition, ever-increasing specialization and diversification creates ever more discontinuities in care and gaps between different types of expertise and doctoring. Finally, efficiency (or economic and production) pressures operate almost on every aspect of our healthcare system, yet there seems to be no concerted, systematic management of these pressures.

 These pressures, about access, cost, time, efficiency, resource utilization, and more, seep into virtually every area of healthcare work. Any leakage that occurs around the edge can be swiftly dismissed as “human error.” Moreover, the creation of cultures of safety seems something that is run mostly by local enthusiasts—champions whose efforts are quickly brought to naught once the hero has left or otherwise been dealt with (co-opted, neutralized).

 Healthcare is not a system that is built for efficiency, or safety, or rational production, or customer service. It might never be, except for some islands of relative stability that pop up here or there. Otherwise the complexities to achieve all these aims are too great, the political pressures and expectations too blatant (and often unreasonable), and the institutional leaning of healthcare towards a pre-industrial past too strong.

Healthcare as a field is extremely gender-skewed and recruits in ways that solidify and reify various kinds of social (and often ethnic) stratification. It has a pervasive and absolute medical competence hierarchy that mimics medieval guilds—with explicit as well as unspoken control regarding access as well as behavioural enforcement strategies. Acceptance of deviance from this (personal, procedural, clinical) goes up with seniority.

 Thus the “justice” dispensed by the increasingly troubling and legalistic “just culture” movement in healthcare is typically perceived as ever less “just” the further down you are on medical competence hierarchy. And, running on a script once developed for witch doctors and shamans, who interlocuted between the living and the metaphysical, and who (ostensibly) ruled over life and death, infallibility remains the system’s working hypothesis. Superhuman working hours and the resistance against the imposition of fatigue regulations confirm the special status of medicine, particularly as a vocation, a calling, rather than a contract-based profession like any other.

 I have no illusions that we can change much about any of this in the short term. But working within these constraints is a challenge that we should be prepared to face.

 Here are a few ways in which we might be able to do that:

  • Instead of asking “Whose fault”? let’s ask, “What happened”?. And more importantly, lets look ahead, rather than back. The variables that explain a particular instance of system failure may not be the same variables that prevent recurrence of similar events elsewhere. Explanatory variables are not necessarily change variables. Error is not an explanation but demands an explanation. The explanatory variables for a medication misadministration, for instance, may include labelling, fatigue, decimal confusion, handover routines and patient idiosyncrasy. The change variable might be a reduction in staff rotation or short-term contracting.
  • Instead of seeing adverse events as isolated events, let’s understand that in a system like healthcare, safety is made and unmade all the time. Safety is a system property, emergent—not resultant from broken or defective components.
  • Instead of stopping when we have found a “human error”, let’s assume that nobody comes to work to do a bad job. Let us accept that errors are systematically connected to features of people’s tools and tasks: they emerge from troubles deeper inside our systems.
  • Instead of investigating people for their failures, let’s investigate events and systems for their improvement potential. Adverse events should not lead to a performance review, but to an event review and to learning.
  • Instead of hoping to find “the root cause,” let’s realize that in complex systems, there is no such thing as a “root cause” and if there is, it is only because we pointed to a particular thing and called it that. Often, normal work, by normal people, embedded within normal system interactions, gives rise to good as well as bad events. Let’s understand how these events emerge, and then try to influence them, rather than assuming we have control over them by removing a “root cause” or “bad apple”.
  • Instead of retributive justice in our responses to failure (the response should hurt because the event hurt too), let us try to seek rehabilitative, restorative justice. If the adverse event hurt, then let us focus on a response that heals rather than one that spreads more hurt. Recrimination can make space for reconciliation—we ourselves are the only ones who stand in the way.

 

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Sidney Dekker (PhD Ohio State University, USA, 1996) is currently Professor at Griffith University in Brisbane, Australia, where he runs the Safety Science Innovation Lab. He is also Honorary Professor of psychology at The University of Queensland. Previously, he was Professor of Human Factors and System Safety at Lund University in Sweden, where he directed the Leonardo da Vinci Laboratory for Complexity and Systems Thinking, and learned to fly the Boeing 737, working part-time as an airline pilot out of Copenhagen. He has won worldwide acclaim for his groundbreaking work in human factors and safety, and is best-selling author of, most recently, Just Culture (2012), Drift into Failure (2011), Patient Safety (2011), and Behind human error (2010). His latest book is Second Victim: Error, guilt, trauma and resilience (2013). 

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