Good to game this out I agree. Much to learn from miscommunications.
Unfortunately I also see another peril here, which is a necessary part of our jobs as physicians - delegation of tasks. Every time we seek help and delegate to medical assistants, nurses, and other support staff, there is a chance someone drops the baton, or worse, is not paying attention and stops running completely. The copilot in your example really dropped the delegated task (you would think he/she would know 5 degrees might be a bad call?)
A nightmare story from a colleague here in Philly was sensationalized by The Inquirer recently. I almost cancelled my subscription. Basically, an Infertility doctor was handed a syringe full of trichloroacetic acid instead of saline to inject. This was drawn up by the medical assistant. An absolute tragedy for the injured patient, and as a physician I can only imagine the horror, shame, and guilt felt by the physician. Instead of recognizing a double tragedy, primarily for the injured patient but also the doc, the Inquirer vilified the doc, and the malpractice lawyers did much the same en route to what will most certainly be a big payout.
We can't do it all as physicians. But when delegation creates mistakes, it makes us want to take this whole enterprise on our own shoulders... which we can't and shouldn't do.
Yes, I could not agree more. I've written *in support* of colleagues who have made devastating mistakes (mixing up medications) which are highly improbably and yet also just about impossible to eliminate entirely without the system grinding to a halt.
The key is that these events should be as close to "never" events as we can possibly attain. That means 1 in a million, not 1 in 1,000.
Our protocols are designed around that, and indeed sometimes those Swiss cheese slices line up. But it's always important to look under the hood to make sure something systemic is not amiss. Thanks for the comment, as always!
Lurking in the background, of course, is your colleague Atul Gawande's focus on checklists - essential to aviation safety, and sadly lacking in much of medicine, where it could be equally critical.
Thank you for this. What is interesting here is that we do in fact have a lot of checklists, which Atul's book and work by others advanced. The problem is that MOST of the checklist kind of suck! They're either too long, or have useless steps. One of my favorite parts of Atul's book is the part where he discussed what makes a good checklist. It's a Goldilocks thing, isn't it.
Thanks :) It used to be really easy to hear the cockpit radio on a lot of flights, so I'd listen. United still has it on some flight, I think.
I'm also always reading random things outside of my field to get tips on phrases I can co-opt. A recent one..."outcome-determinant." I love this one (got it from the Jack Smith indictment). I like the ideas that there can be problems and mistakes but that does not mean they affect the outcome of whatever you're doing. So, I can give 1 gram of an antibiotic when the official weight-based dose is 1.1 grams. This deviation would not outcome determinant. But if I give 0.5 grams, it could be.
Outcome determinant should be used in determining which flags go up on EMRs- i.e. if I am prescribing an antibiotic at 1000% of typical weight based dose the alert should go off, but prob not at 105% which is probably a rounding error
This was a good informative explanation of communication protocol. Thanks.
Glad you found it interesting!
Good to game this out I agree. Much to learn from miscommunications.
Unfortunately I also see another peril here, which is a necessary part of our jobs as physicians - delegation of tasks. Every time we seek help and delegate to medical assistants, nurses, and other support staff, there is a chance someone drops the baton, or worse, is not paying attention and stops running completely. The copilot in your example really dropped the delegated task (you would think he/she would know 5 degrees might be a bad call?)
A nightmare story from a colleague here in Philly was sensationalized by The Inquirer recently. I almost cancelled my subscription. Basically, an Infertility doctor was handed a syringe full of trichloroacetic acid instead of saline to inject. This was drawn up by the medical assistant. An absolute tragedy for the injured patient, and as a physician I can only imagine the horror, shame, and guilt felt by the physician. Instead of recognizing a double tragedy, primarily for the injured patient but also the doc, the Inquirer vilified the doc, and the malpractice lawyers did much the same en route to what will most certainly be a big payout.
We can't do it all as physicians. But when delegation creates mistakes, it makes us want to take this whole enterprise on our own shoulders... which we can't and shouldn't do.
Yes, I could not agree more. I've written *in support* of colleagues who have made devastating mistakes (mixing up medications) which are highly improbably and yet also just about impossible to eliminate entirely without the system grinding to a halt.
The key is that these events should be as close to "never" events as we can possibly attain. That means 1 in a million, not 1 in 1,000.
Our protocols are designed around that, and indeed sometimes those Swiss cheese slices line up. But it's always important to look under the hood to make sure something systemic is not amiss. Thanks for the comment, as always!
Lurking in the background, of course, is your colleague Atul Gawande's focus on checklists - essential to aviation safety, and sadly lacking in much of medicine, where it could be equally critical.
Thank you for this. What is interesting here is that we do in fact have a lot of checklists, which Atul's book and work by others advanced. The problem is that MOST of the checklist kind of suck! They're either too long, or have useless steps. One of my favorite parts of Atul's book is the part where he discussed what makes a good checklist. It's a Goldilocks thing, isn't it.
Super Faust. No wasted Words. Love ER Docs.
Thanks :) It used to be really easy to hear the cockpit radio on a lot of flights, so I'd listen. United still has it on some flight, I think.
I'm also always reading random things outside of my field to get tips on phrases I can co-opt. A recent one..."outcome-determinant." I love this one (got it from the Jack Smith indictment). I like the ideas that there can be problems and mistakes but that does not mean they affect the outcome of whatever you're doing. So, I can give 1 gram of an antibiotic when the official weight-based dose is 1.1 grams. This deviation would not outcome determinant. But if I give 0.5 grams, it could be.
Outcome determinant should be used in determining which flags go up on EMRs- i.e. if I am prescribing an antibiotic at 1000% of typical weight based dose the alert should go off, but prob not at 105% which is probably a rounding error
We do the same when sailing, when wind can make comms hard to hear. Great reminder. Thanks.