oCtoBeR 2010 - American Association for Clinical Chemistry

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ask tHe expert How to Categorize Incident Reports to Fuel Quality Improvement A Model-Based Approach for Process and Behavior Incidents PeGGy a. aHlin, Bs, Mt(asCP) anD Bonnie MessinGeR Peggy Ahlin is director of quality and compliance and Bonnie Messinger is quality manager at ARUP Laboratories in Salt Lake City, Utah. What is a practical approach to categorizing incident reports so that incident reporting fuels quality improvement? As with any task, it is important first to define the goal. What information do you wish to capture? And more important, what do you plan to do with it? The obvious intent is to facilitate process improvement and/or promote behavior change. Some incidents can be traced to poor process design, while others are the result of human fallibility. In general, it makes sense to categorize process improvement changes by areas of focus, such as process control systems; however, behavior change categories should center on interventions. Table 1 provides an example of a useful model for categorizing behavioral incidents. This model is helpful because it provides guidance for the most appropriate interventions. For example, lab managers would respond to employee judgment errors related to the lack of rules by creating the necessary rules and training to those incidents involving reckless violations of rules, like destruction of computers in the laboratory, usually mean that the employee is not a good fit for the workplace. 14 CliniCal laboratory news oCtoBeR 2010 rules. Judgment errors related to reckless or intentional behavior would be reduced or eliminated by disciplining or terminating the employee, or finding a better fit for the employee in a position with less risk. Likely candidates for the process improvement categories are those used in your organization’s quality systems. This approach allows you to focus on improvement strategies that match the quality system you want to improve. For example, according to the Clinical Laboratory and Standards Institute’s Qual- ity Essentials model, mislabeled specimens would fall within the process control system. Adding tiers of categories such as preanalytic (mislabeled specimen), analytic (testing of a mislabeled specimen), and post-analytic (reporting a result inconsistent with a historical value) could also help refine the focus of your response. Other possibilities for categories are the major steps in your organizational flow chart or value stream map. The number of tiers you choose will determine the granularity of your process review. One caution: with each higher level of granularity, the number of categorization choices will increase exponentially. If there are too many choices, users will have difficulty finding the most descriptive sub-category. If this happens, the data is less valuable for focusing your quality improvement efforts. In summary, the best approach to categorizing incident reports enables users to accurately categorize both process- and behavior-based incidents, significantly help- ing your quality improvement efforts. table 1 model for categorizing behavioral incidents Judgment error—involves choosing between possibilities; requires synthesis Description Why Response No rule Rule doesn’t fit Reasonable rule violation Reckless rule violation No rule in place; employee made the best decision based on the information at hand Event is rare or has never happened before and no rule is in place. Rules cannot cover every scenario. Console the employee; relieve the employee of taking unreasonable risk or being responsible for decisions above their level of authority Rule is in place, but is commonly not followed (takes too much time, is difficult, a workaround is a better process and is commonly used) Benefit of breaking the rule exceeds the risk of being caught Revise the rule or remove the incentive for violating the rule Rule is in place, but employee chose not to follow because doing so would cause more harm than violating the rule Rule doesn’t cover every scenario; employee’s judgment failed to take all variables into account Coach the employee. If the employee was right, support the employee’s decision and consider revising the rule Rule is in place, but employee chose not to follow. Reason for that choice was not patientcentered Sabotage; willful disregard for patient safety; social proof; dilution of responsibility Employee is not a good fit for this job; terminate the employee or move to a different job without risk potential Knowledge error—involves learning, application of knowledge and memory; requires cognition (If the employee knows what to do, but acted in error, consider judgment-based error) Description Why Response Didn’t know Should have known Would have known Couldn’t know This event is covered in training, but was not covered with this employee Employee was not trained for this task or this module was missed during training This event is covered in training This event is covered in training in a general sense; under different circumstances, the knowledge would have been applicable Employee was inattentive at this moment in training or forgot; mental blink Employee did not synthesize the training to related scenarios Train Retrain; consider memory aids Train for synthesis; consider ways to judge level of or capacity for synthesis This event is not covered in training; there is no training module; no SOP Training module is incomplete; event is rare and is not included; training module/SOP has not been developed Consider adding to training or (better) training for synthesis; develop training module/SOP skill-based error—involves automatic task or manual manipulation of an object; requires dexterity (If the employee has demonstrated proficiency and has been trained, consider knowledge-based or judgment-based error) Description Why Response Inept (low effort) Inept (best effort) Proficient (best effort) Proficient (low effort) Employee struggles to perform; attempts to train are ineffective and unwelcome The employee’s physical or mental faculty is not a good fit for this job; the employee is unwilling to train for better performance Consider a different assignment; explore employee’s unwillingness; look for goal conflicts, poor leadership and personal stress; consider that employee’s motivation may not be a good fit for this job Employee struggles to perform; attempts to train are welcomed The employee’s physical or mental faculty is not a good fit for this job; the employee is willing to train for better performance Train for better performance; consider ergonomics, environmental conditions (light, heat, noise), fatigue, breaks. Consider a different assignment Employee has demonstrated the ability to perform; attempts to train are welcomed The employee’s physical or mental faculty is a good fit; the employee is willing to train for better performance Train for better performance; consider ergonomics, environmental conditions (light, heat, noise), fatigue, breaks Employee has demonstrated the ability to perform; attempts to train are ineffective and unwelcome The employee’s physical or mental faculty is a good fit; the employee is unwilling to train for better performance Explore employee’s unwillingness; look for goal conflicts, poor leadership and personal stress; consider that employee’s motivation may not be a good fit for this job
patient safetY concepts The Monday Morning Quarterback Hindsight Bias in Medical Decision Making By KaRen aPPolD Have you ever heard someone say, “I knew that was going to happen?” But everyone knows that predicting the future always becomes much easier once the future is in the past. Sayings like “hindsight is 20/20” and “Monday morning quarterback” are also popular ways to describe such predictions. These expressions refer to what psychologists call hindsight bias, the tendency for people to regard past events as expected or obvious, even when in real time the events perplexed those involved. Safety analysis experts are now applying the hindsight bias model to medical decision making. Here hindsight bias describes the tendency to judge the events leading up to an accident as errors because the bad outcome is known (1). Take, for example, the way in which clinicians interpret a lab result. The clinician has a certain amount of information that allows him to assess the probability of a diagnosis or likelihood that a condition will worsen. He then makes decisions based on those probabilities. However, when authorities, like a consulting clinician or an expert witness, assess whether or not the treating physician made a good decision, and the outcome is unknown, the experts will often support the decision. But if the experts learn that a patient had a negative outcome, then they are more likely to think that the decision was poor. In other words, knowing the outcome in the present affects the experts’ analysis of events in the past. This thinking process is a universal human phenomenon. “Cognitive psychologists have realized that hindsight bias is almost unavoidable. When a negative outcome occurs, the tendency is to think that if a different action would have been taken, the outcome could have been prevented,” explained Rodney A. Hayward, MD, director of the Robert Wood Johnson Foundation Clinical Scholars Program and professor of medicine and public health at the University of Michigan in Ann Arbor. “Ultimately, a decision is made with the intent to reduce the risk of something bad happening. But any action bears certain costs and risks.” Hayward recalls a particular scenario involving a lab test result that shows how hindsight bias can easily happen. A patient’s creatinine level increased from 1.3 to 1.6 units over 3 months. The patient appeared to be fairly stable, so the clinicians weren’t too concerned and scheduled a follow-up visit in 3 months. Three weeks later, however, the patient was hospitalized because his creatinine level spiked. Upon reflection, the clinicians questioned whether they should have re-checked the patient sooner. “But the reality is that the difference between those two creatinine levels is not that unusual and is almost within the range of lab error,” Hayward said. “In addition, it is unclear if that slight bump was a warning sign. If we re-checked everyone with such a slight increase, we would constantly inconvenience patients and it would be costly.” This is a good example of hindsight bias in medical decision making because when something negative happened (the patient was hospitalized), the original decision (to not re-check him earlier) was questioned. But if the decision was evaluated in monday morning quarterbacking in medical decision making can be minimized if decisions are evaluated based on the information available at the time of the decision, and not after the outcome is known. examples of hindsight bias ® “i knew they were going to lose.” ® “that’s exactly what i thought was going to happen.” ® “i saw this coming.” ® “that’s just common sense.” ® “i had a feeling you might say that.” real-time, most likely everyone would have agreed that a routine 3-month follow up appointment was appropriate and the slightly higher creatinine level was not of concern. To minimize hindsight bias in this instance, clinicians should question whether a patient with such a small change in creatinine level in a 3-month period should be rechecked weekly. In general, a good technique for minimizing hindsight bias is to formally consider alternative explanations that do not involve errors. In fact, making too many changes based on small random errors in lab tests can actually have negative outcomes. “Some research suggests that if you check an international normalized ratio (INR) to monitor warfarin therapy too frequently and make constant adjustments, you will actually do less good than if you check it at slightly longer intervals and make smaller adjustments. This is because you may overcorrect for random variations in INR by getting too much information from lab tests,” Hayward explained. To some degree, hindsight bias can’t be completely avoided. “When we criticize certain decisions and policies, we need to consider the cost, as well as the risk and consequences of alternative actions.” One problem with hindsight bias is that it leads us to criticize or even punish healthcare workers who make decisions that lead to poor patient outcomes. To avoid the negative consequences of hindsight bias, Hayward advises against adopting new policies or punishing employees without reflecting on the full process. It is better to evaluate whether the decision was reasonable and determine the best action to take in the future. REFERENCE 1. Hindsight bias. Available at: http://psnet. ahrq.gov/glossary.aspx#hindsightbias. Accessed August 13, 2010. Karen Appold is an editorial consultant for the clinical laboratory industry. Email: karenappold@comcast.net patient safety focus editorial board chair michael astion, md, phd department of laboratory medicine university of washington, seattle members peggy a. ahlin, bs, mT(ascp) arup laboratories salt lake City, utah James s. hernandez, md, ms mayo Clinic arizona scottsdale and phoenix devery howerton, phd Centers for disease Control and prevention atlanta, ga. CliniCal laboratory news oCtoBeR 2010 15
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