NEW LOOK

SUMMARY Methods of detecting errors and preventing adverse outcome have been developed and proved effective in other industries. Such methods can be adapted to healthcare.

The hallmarks of this innovative approach are systems focus, inevitability of error, cross-monitoring and non-hierarchical communication.

"New Look"1 is challenging the traditional medical view of error.

When conscientious caregivers make mistakes, their ingrained professional values of personal responsibility, autonomy and accountability trigger psychological defences of repression, projection and denial: "don’t wash dirty laundry in public - I wasn’t told - it was the underlying disease, not the error."

Other high-risk industries, such as aviation2 and aerospace, have developed ways of dealing with mistakes that work considerably better. They have thereby reduced error to levels many magnitudes lower than that of health care3. These approaches, it is proposed, can and should be adapted for the health industry.

It would be unthinkable for the aviation industry to injure 1 million Americans every year and kill 100,000, as errors during hospitalisation are claimed4,5,6 [full-text] to do.

Practical Pointer

Characteristics of New Look:

  • Emphasis on systems rather than people
  • Non-punitive approach
  • Emphasis on the multifactorial nature of error
  • Assumption that errors will occur
  • Emphasis on caregiver interactions
  • Sharp end, blunt end
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    The hallmarks of this innovative approach are systems focus, inevitability of error, cross-monitoring and non-hierarchical communication.

    Systems rather than people

    In marked contrast to the underlying assumption that competent caregivers will personally detect and correct the mistakes that they rarely make, this approach acknowledges that errors are inevitable2. Redundant and dynamic safety procedures that include cross-monitoring (continual mutual evaluation) of all caregivers is the new paradigm.

    Non-punitive approach

    A steady trickle of confidential, internal enquiries for corrective feedback is the mark of a healthy organisation. Such activity is desirable and should not trigger accreditation watch.

    Multifactorial nature of error

    The error that results in an adverse outcome is the tip of an iceberg. Focusing on one or two factors that are readily identifiable is counter-productive: the underlying vulnerability caused by, for instance, understaffing, fatigue, or distractions must be acknowledged and addressed.

    Assumption that errors will occur

    The systemic approach includes creating an environment inimical to error, facilitating early detection, and designing buffers to minimise patient harm from inevitable errors.

    Emphasis on caregiver interactions

    Intrinsic to the traditional approach are hierarchy, territory and other obstacles to cross-monitoring. Interprofessional communication skills, including assertiveness training, must be taught and fostered. Such teamwork was difficult to achieve in the aviation industry (hierarchy and rank) and will be difficult in healthcare.

    Sharp end, blunt end

    De-emphasising the "sharp" end of the patient-caregiver interaction, and concentrating instead on the "blunt" end of organisational and resource-allocation factors is as essential as it is unpopular.