A Tale of Two Stories
National Patient Safety Foundation
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Report
from a Workshop on |
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Introduction
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Increased Visibility for Patient Safety Recent accidents in health care have fueled a growing interest in patient safety. These highly publicized accidents have occurred against a backdrop of substantial changes in the organization, delivery, and economics of health care. Together, these events lead to substantial public pressures to make progress on safety. As a result, many health care organizations are focusing more on patient safety. For example, patient safety has been the theme of major health care meetings (e.g., "Examining Error in Health Care: Developing a Prevention, Education and Research Agenda," held October 1996 at the Annenberg Center for Health Sciences, Rancho Mirage, California.), a 1998 Presidential Advisory Commission on Health Care has included patient safety as a high national priority, and major journals have recognized the topic (Leape, 1994). The widespread interest leads immediately to two questions: "How do we make progress on patient safety in the longer term" and "What are the 'low hanging fruit' that we can pick to have an impact quickly?" Many interested parties have widely varying ideas about the answers to these questions. Some consumer advocates desire greater public access to records about the past performance of physicians or hospitals. Other commentators promote technology as the key to progress, for example, proposing computerized physician order entry to reduce medication errors. Many want to implement more accident or 'close call' reporting systems to help identify troublespots. How do we sort through all of these varying proposals? On what basis do we decide which proposals merit investment and change? However plausible and beneficial each proposal sounds, how can we be assured it is based on an accurate understanding of the complex factors at work? Can we distinguish approaches that will produce real progress and enhance safety from those that will lead to dead ends?
Research
as a Guide for Progress
A research base on the human contribution to safety and failure in areas outside medicine has been built up over about the last 20 years. This base of knowledge has come from an intense cross-disciplinary examination of this topic driven by a series of highly visible accidents, as well as other less celebrated cases, in industries such as power generation and transportation (e.g., Three Mile Island nuclear power accident in 1979, the capsizing of the Herald of Free Enterprise in 1982, and various aircraft accidents). The participants in this work have come from a variety of disciplines including human performance, cognitive psychology, social psychology and organizational behavior, among others. To make sense of these accidents and to develop ways to enhance safety, various researchers have collected data about the multiple human, technological, and organizational factors that contribute to accidents; investigated the normal functioning of these settings; developed new concepts and theoretical frameworks; and re-examined common assumptions. The result has been a "new look" at the human contribution to both safety and risk (e.g., Reason, 1990; 1997). This "new look" is based on research that goes beyond the label "human error." The usual judgment after an accident is that human error was the cause, a conclusion which often serves as the stopping point for the investigation of the case. As a result, safety problems typically are seen solely or primarily as "human error" problems. In contrast, when the label human error becomes the starting point for investigations, we find a deeper, multi-faceted story. This "second" story shows us how multiple interacting factors in complex systems can combine to produce systemic vulnerabilities to failure. The second story is more complicated but more interesting and can point the way to effective learning and system improvements. A National Patient Safety Foundation Workshop The National Patient Safety Foundation (NPSF) is a new organization
dedicated to advancing safety in health care. Among other initiatives,
the Foundation is committed to learning about, using and adding
to the established research base on safety. To this end in December 1997, a workshop format was used to bring together some 20 researchers and an equal number of interested leaders from health care. Each researcher is an internationally acknowledged expert in some aspect of human performance evaluation, cognitive psychology, or organizational behavior (a list of the participants is attached in Appendix A). The overall objective of the workshop, "Assembling the Scientific Basis for Progress on Patient Safety," was to develop a basis for providing sound technical advice to the National Patient Safety Foundation, a basis grounded in the research on human error, system failures, and organizational factors. The workshop was conducted as a wide-ranging, highly informed conversation that played off the contrasts between celebrated medical failures and other cases that are less publicized but contain a significant research base on human performance. A Sourcebook of materials about the celebrated and uncelebrated cases helped participants prepare for the workshop (see Appendix C for a list of the articles). The "celebrated" cases, as a group, capture the reactions of different stakeholders to medical failure. The explanations for how these cases came about are a kind of story we, as a society, tell after the fact in order to learn from the failure and to decide what kinds of changes are needed. In telling that story stakeholders focus on a few of the factors and actors that could be seen as contributing to the sequence of events. Which factors and actors come to be regarded as most responsible depends on the kind of stakeholder, common beliefs about the role human performance, common beliefs about why systems succeed and fail, and the normal human processes for attributing causes to surprising events. The story that results represents a model of the threats to patient safety and presumes that certain changes will address or eliminate these threats. This treatment represents the "first" story. In contrast, another set of cases, uncelebrated but well researched, reveal a "second" story. This story captures how the system usually works to manage risks but sometimes fails. When researchers pursue the second story they broaden the scope of inquiry in ways that lead them to identify systemic vulnerabilities that contribute to failures. The result is a very different view of the patient safety landscape, a view that highlights many factors that the first story ignores. Each uncelebrated case yields interesting results but together they have broad implications for how to make progress on patient safety. Analyzing the uncelebrated cases as models of patient safety research represents a substantial departure from the usual, first story based approaches. The concepts and methods used in the research for these cases can serve as a model for approaches to other areas in health care. The workshop also examined lessons from incident reporting and analysis activities in other domains. This topic often is cited as a key initial step toward enhanced safety in health care. The departure point for this portion of the workshop was a presentation on the lessons learned as aviation safety experts sought to develop a system for collecting and analyzing incidents. An edited version of this brief, but powerful presentation is attached in Appendix B. The workshop used the contrasts between first and second stories to evoke participants' comments about research on patient safety. The result was a dynamic and complex exchange. The discussion did not point to any simple answers. Rather it produced some strong indications of where and how fundamental progress can be made. It also showed how some of the approaches health care organizations often adopt have proved to be of limited value in other settings. The contrasts between these two kinds of stories about patient safety also provide the structure for this report. The report conveys much of the flavor of being there, but does not attempt to reproduce the entire discussion. Instead, it represents the authors' construction of the central themes and concepts that emerged from the discussion, based on an analysis of the verbatim transcript of the meeting and the sourcebook materials. Far from being the final word on these important topics, we hope the contrasts captured in this report will broaden other discussions of safety and ground these debates in the basic results from past research. Health Care After Its "Three Mile Island" |
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Annenberg Center for Health Sciences |