Human Factors and Hernia Repair - What you were not told......

 

I have written about hernia repair and recurrences previously.

A fairly common surgical procedure such as hernia repair involves a number of human factors.

Pause now, think and imagine the human factors involved in a successful routine primary inguinal hernia repair.

 

So I asked AI (ChatGPT)

What are the human factors involved in a successful primary inguinal hernia repair?

Chat GPT answer was:

The human factors behind a successful repair can be summarised as:

Preparation → situational awareness → effective communication → teamwork → appropriate challenge → cognitive flexibility → ergonomic working → fatigue management → reliable checking → reflection and learning.

Claude gave this answer to a similar question:

The dominant human factors challenge is therefore data capture, audit culture, and willingness to have practice scrutinised, rather than technical dexterity alone.

 

If you were a surgeon, or an anaesthetist, or a theatre nurse, or any member of the surgical team, that is exactly what you would have been taught as human factors.

Those would be true for variables that do not have a technology based physical design solution.

One of the important crucial end points of a successful primary inguinal hernia repair is the recurrence rate.

Historically, the recurrence rate was 30% to 40%.

Currently the recurrence rate is 1% (in some research publications) and up to 10% in practice.

Were the surgeons of the past technically incompetent? Has the groin anatomy changed? Were the surgical teams of the past not paying attention to the human factors listed above by Chat GPT?

I don’t think you would say yes to any of those questions.

What made the difference was the introduction of a physical technology based design in the repair of an inguinal hernia – a MESH.

That reduced the recurrence rate.

Every behaviour based  point mentioned above and repeated here, namely Preparation → situational awareness → effective communication → teamwork → appropriate challenge → cognitive flexibility → ergonomic working → fatigue management → reliable checking → reflection and learning; are important as an additional layer on top of the physical design but unlikely to make a significant impact on their own.

 

Healthcare Human Factors is so distorted that we do not readily consider physical technological design as a component, never mind the main component of human factors.

 

I address this issue extensively in my book : “Look for the design – Clinical Human Factors – Humans execute and ‘machines’ guard.” https://www.amazon.co.uk/dp/B0HC4M1ZBT

The above example is not in the book but is a bonus for the readers of my blog.

Give the book a read and let me know what you think.

 

 

https://www.amazon.co.uk/dp/B0HC4M1ZBT 

Design is the key for human factors. Behaviour is a small bonus.

 Design is the key for effective human factors

In a recent famous case, one surgeon and two anaesthetists were said to be anaesthetising two patients at the same time; this would be risky and unnecessary for patients to be anaesthetised for longer than absolutely essential. It is unethical.

https://theworldnews.net/gb-news/derek-mcminn-patients-put-in-danger-so-scandal-hit-surgeon-could-perform-two-operations-at-same-time

The question is: how did this even happen? There must be policy in place to prevent this. There must have been people who could and should have questioned this and prevented this. Sure. Let’s assume we had policies and people in place – do they prevent for sure two patients being anaesthetised for the same one surgeon at the same time? No.

It happened because there was the structure, infrastructure and facilities to do it.

In UK hospitals there is something called the anaesthetic room which is separate from the operation theatre. This means for one surgeon, there could be a patient anaesthetised inside the operation theatre and another patient anaesthetised in the anaesthetic room.

This is a fairly unique UK NHS practice. Historically, the subsequent patient was brought into the anaesthetic room and the process of anaesthesia began or anaesthesia given when the patient on the table in the operation theatre was nearly done. This was thought to be efficient. It worked when the so called ‘registrars’ both anaesthetic and surgical were experienced. This anaesthetic room concept was then followed by UK private hospitals.

The presence of the anaesthetic room means that it would be physically possible for two patients to be under anaesthetic simultaneously for a single surgeon.

Recently, when designing the theatres of a private hospital, we argued for not having an anaesthetic room and prevailed.

This means that in that private hospital which does not have an anaesthetic room, there is no possibility of two patients being under an anaesthetic at the same time for a single surgeon because there is no physical infrastructure/facility that enables/allows it. No policy or person(s) would have been able to achieve this.

We cannot design a problem to be built into a system and then expect policies and people to overcome it consistently.

Design is the fundamental for human factors – people and behaviours are simply an add on bonus.

© Hemadri

Ebbinghaus Illusion : Philosophical and Human Factors thoughts

The Orange Circles, both of them are exactly the same size. However, at a quick glance, it is very obvious that one looks bigger than the other.

Philosophical questions

The first question is which orange circle would you like to be? Small fish in a big pond or big fish in a small pond? Why? If you are the fish, do you realise that the fish is the same irrespective of the pond. Are you living in hope? Are you living in false hope? Do you think the big pond means that you have a great opportunity etc? The size of the pond does not allow the fish to become bigger or smaller.  Is it a protection mechanism that you are using? Small fish in a big pond, are you trying to hide to protect yourself? Are you trying to be insignificant? Do you fear that you might be attacked by predators? Big fish in a small pond, are you the predator? Are you trying to show off and dominate? If you are, what impact is that having on your eco-system?

Political questions

If you are surrounded by ‘small’ people it may make you seem/feel big and if you are surrounded by ‘big’ people it may make you seem/feel small – would you be aware of that? How comfortable would you be with that? What would upset you? How can you use it to your advantage?

Human Factors perspective

What goes on around you can distort your perception. We also know that our perception is our reality. We face adverse effects for ourselves and create adverse effects for others by distorted reality.

Let us say you are selecting someone for a job or a promotion and you faced this distortion and always picked what you thought was a bigger orange circle, you would be causing chaos and confusion. Let us say both the orange circles are urgent medical conditions and you constantly chose the ‘larger’ one you would continuously disadvantage one particular group of patients.

Similarly, when gearing up for tasks, you could be under prepared or over prepared depending on how you perceive. You could then face surprises, nasty surprises that could harm. It is this kind of illusion that results in over estimating our strengths and underestimating our weaknesses.

It is okay for poets to talk about the moon being larger and closer or smaller and farther but when it comes to operations of any kind but especially in healthcare - Measurement and objectivity are important, they become even more important in complex situations.

©M HEMADRI

Follow me M HEMADRI on Twitter @HemadriTweets

M Hemadri’s mini e-book 'Standardised Management Conversation' is available - click http://www.amazon.co.uk/Standardised-Management-Conversation-Hemadri-ebook/dp/B018AWBJTU 

Ref:

https://en.wikipedia.org/wiki/Ebbinghaus_illusion

Image from:  https://s-media-cache-ak0.pinimg.com/originals/19/f1/2b/19f12b63aed88a94b25e87044d9b0a3a.jpg 

Blame it on human error

Blame it on 'Human Error', after all everybody knows that to Err is Human

Can you see what is happening in the pictures above? Of course you can. They are two infusion pumps with two different types of numerical key pads.

Can you now see how easy it would be for a tired nurse or an even more tired doctor when they are really busy at 3 am to confuse between the keypads and make a mistake?

Would that be counted as human error? Probably yes. But is that human error? Certainly not. This situation would be without doubt a systems error at two levels. Firstly for the manufacturers not standardising numerical keypads. Secondly for the buyer/healthcare facility for buying and using pumps with two different key pads in their premises. By doing so we have designed our system to fail, we have designed for the humans in our systems to fail. Avoiding that is what human factors is all about.

Let us assume that a clinician made an error in a facility that both these styles of numerical keypads in use in say adjacent beds/wards/floors. The investigation would only show that the clinician made a human error in pressing the wrong numbers in that particular key pad. That would be a fact. Would that be the whole truth? No. A standard investigation would not show that the error was triggered by the system by having those two types of keypads in adjacent areas. The investigation would probably end by stating that individual clinicians are responsible for their actions. Then the clinician would be sanctioned against, sometimes that is insultingly yet euphemistically called providing enhanced support and training for the concerned clinician.

The reason called 'human error' becomes a convenient parking lot for system errors that mostly go unrecognised due to poor management and poor investigators who have not much clue about human factors. Human error is easy, its tangible, you have someone clearly responsible and someone who has failed in their responsibility. Every one understands human error. System error recognition is very complex, its often fuzzy, once recognised there is no one to 'blame', to be held responsible. After all that, resolving system errors takes patience, time, energy and technical skills which many would pretend to have. It is frightening to imagine how many clinicians might have been afflicted with the 'human error' label when the actual reason was the system.

Now, if you were remotely responsible for patient safety, you will now rush out into your healthcare facility to make sure that you have only type of numerical keypads at your facility for these. That is at the narrow level. At the intermediate level please ask yourself how many other items that are non-standard at your place of work that confuses people and compels them into making an error. Go looking for them and eliminate them.

At a bigger picture level we are beginning to believe that 'Human Error' is often a cop out clause for managers who don't fully understand systems or processes. To err is indeed human but to design for failure and then blame it on 'human error' is inhuman.

©M HEMADRI 

Follow me on twitter @HemadriTweets

PS: Note the manufacturer of the pumps in the picture above is only an illustration to make a wider point, those pumps are good and overall have served patients well.  So please do not get hung up and pious about a particular product or company. I have also found that my windows calculator and my samsung phone calculator have different numerical keypads which are different from my computer keyboard's numerical keypad. How confusing is that? Is it any wonder then if some poor bloke at the office goofs up? 

Letter to my nieces

A letter to my nieces

Sam (USA)

– who has just joined med school this year

&

Mayank (India)
- who completes med school this year

Dear Sam and Mayank

Congratulations. Sam you have done well to get to med school. Mayank you have done great and will finish med school later this year. You are in the top 2% of the academic performers and you will continue to remain there at least till you begin independent clinical practice, hopefully many decades into your clinical practice.

I write this in joy but more relevantly to provide you another window for your intellect and for your practical development.

I did Anatomy, Physiology and Biochemistry in my first year at med school. There are not many more accurate and fact based subjects than these in medical education. Fact after fact, learnt day after day. We realised that these facts were the foundations of our future careers, we took it really seriously. We demonstrated our mastery (okay, personally I just demonstrated my mere competence) by passing tests and exams. It was tough. It was worth it. I was satisfied that my foundations were good.

These fact based subjects left an indelible impression in my mind that medicine and its practice was based on accuracy and facts. When the facts varied, such as when the cystic artery was double or it was low lying and so on, they were grouped into sub-facts to be remembered for future reference and practice. Some facts were actually a range of facts as in the normal range of plasma sodium values and so on. Later on while attending physiology classes at the Royal College of Surgeons at Edinburgh, the tutor would squeal in dominant delight ‘either you know it or you don’t’; no more powerful, explicit message for post-graduate doctors about the need to be precise and accurate. A message that I heard many years earlier in first year med school and repeatedly thereafter.

As we moved along we recognised that subjects like pathology and microbiology begin to interfere with subjects like anatomy and physiology and gives rise to trouble in real people. Help was at hand for us to understand that. Pathology text books showed clear microscopic slides on how every pathology looked, again where there were variations they were classified as yet another group of facts.  I got the impression at that time that if that’s how it looked, that is what it must be. That kind of thinking was compatible with the fact based approach of anatomy and physiology. All this knowledge was then put to practical use by learning even more glamorous and glorious subjects such as surgery, internal medicine, gynaecology, et al. Those were exciting days.

We continued to learn from revered text books on the one hand and from revered teachers on the other. Patients had clinical problems, we used our knowledge to diagnose them (CT scans were extremely rare when we were medical students and ultrasound scans were just taking off and x-rays in general provided basic support) and applied our knowledge to treat them. Of course things did not always go well for patients, we still call them complications or morbidity, sometimes patients died, we classify that as mortality.

As we gained experience often as post-graduate doctors we began to realise that all of our revered teachers did stuff very differently from each other while they were dealing with similar problems. The cleverer of the lot justified their different styles of practice by references to science, the rest told us that their experience suggested that their practises were valid. Our professors and consultants told us that they acquired their wealth of knowledge so that they can give their opinions. One sudden day we recognise that we learn medicine on the basis of knowledge and practise it on the basis of opinion. On the basis of very very widely varying opinion.

We begin to wonder. If the learning in undergraduate medicine was based on accurate facts, why is the practice of real world medicine on the basis of hugely varied opinion? We brush aside these discomforting thoughts. We have not only made a huge investment in our knowledge but also in our method of acquiring and practising that knowledge.

Pathology text books did not tell us that two pathologists looking at the same slide could give you two different opinions, not often but certainly possible in the definition of complex cases. We were never told that the text books that we read were by definition about five years out of date or that at worse some of the editors edited those books while travelling in their ultra-luxury cars between various locations of their private practices or at best after a couple premium alcoholic drinks in their study. We were realised that when our teachers said the words ‘in my experience’ it did not mean objectively measured operational experience but meant their personal subjective understanding of how they thought they performed.

In medical practice there is evidence for everything and there is evidence for nothing. This provoked David Eddy, the American father of evidence based practice (oh, by the way evidence based practice has two fathers one American and one British) I believe to say something like that you can find two physicians to testify in court to the exact opposite views.

Nobody will tell you yet that

Substantial activity in clinical medicine is not performed on the basis of clear unequivocal evidence
Substantial activity in clinical medicine cannot after care delivery find evidence to back it
Substantial clinical care is delivered incompletely
Substantial amount of errors are found in the delivery of care
Substantial numbers of clinicians are either unable or unwilling to accept the above

These issues are not just academic, they have great direct impact on patients and their lives. We did not know at med school that there was an entity called avoidable mortality; when we first heard about it we found it unbelievable for the reason that if it was avoidable us clever and experienced doctors would have already avoided it. We did not know at med school that practice of healthcare is highly error prone and extremely unsafe; when we came to know about it we did not believe it. Despite this we and the public, trust ourselves - the medical profession; we trust our high intelligence, our extreme hard work or proven record of success for ourselves and for our profession. We are brilliant and we have faith in ourselves.  The brilliance of the medical profession is also blinding itself.

The lack of evidence and the opinion based practice results in hierarchical power games. Those who are unable to play become bad apples initially and ‘poor performers’ later. Now, imagine that, top scores at school graduation, long mind numbing hours of hard work for years, proven success in exams and other challenges, then eventually being called incompetent or poor performer or some other derogatory term by people who practice the art of medicine while imagining it to be based on facts and evidence. Worse still these phenomena perpetuate the wide clinician generated variations in practice. Doctors are intelligent and learned enough to be able to justify their individual practices as evidence based; that is of course true. What is important to understand is that their justification is based on the evidence they choose to base it upon. My evidence is the truth and nothing but the truth but not the whole truth. Simply because firstly the whole truth probably is not already known, secondly the whole truth is too vast to know and thirdly in healthcare the whole truth often has a tendency to contradict itself.

I write this not in despair, not to distract you, but to give you hope. Because the solutions for embracing a world of wrongness and still do good to the maximum number of your patients are already out there. I want to briefly introduce you to that world and I want you to be aware of it. These are the shades that you wear when you are out in the bright sun, it will also make you look cool. It might make you comfortable in a world of contradictory evidence.

In conventional science based research oriented world there is probably nothing that is absolutely true; there is a current hypothesis which we attempt to validate or reject and the hypothesis stands till it is rejected. You will find that most hypothesis in medicine are rejected over a period of time, this gives rise to problems in clinical practise as the research that is good today becomes ‘false’ very soon. However, that is how research and science works. That is how it should work. However, in our routine clinical practice we do not work as researchers, we work as operational practitioners. My suggestion therefore is to look at operational methods for a good clinical practise and use to them to the best benefit for your patients. These derive from the shared baseline approaches devised by Brent James and his team at Utah.

At a basic level, a good shared baseline method looks like this

-         - You agree with your immediate and local colleagues on a protocol for most common problems that are seen in your clinical practise

-         - You track the outcomes over time of some of the process and outcome parameters of the protocol that you have agree

      - You amend your protocol based on the outcome tracking

-         - You show deep and genuine respect for everyone who works with you

-         - You share and learn operational clinical day-to-day practise first and primarily with/from your immediate and local colleagues before you do so with the rest of the world

Intermountain Healthcare does this, they probably discovered this method. IHI recommends it (I suggest you become members of IHI open school), people at Mayo, Virginia Mason, Jonkoping and a few others have their own versions of this. The method though, is not one of a pick and mix buffet, one has to do them all or get no benefits from them.

I suggest that you start exploring this kind of thinking in parallel with your conventional learning, not for fact based subjects but for the rest of them. We are all creatures of habit, attitude and cultures. It will be very difficult to change once certain mindsets are established. The energy and effort required to do it now in parallel is much less than to do it later. Your patients will get remarkably far better results and your systems (your patients, insurance, hospital, yourself) will spend far less on a like for like basis.

Many doctors will understandably be either uncomfortable or unwilling to accept or follow this kind of practice. They will deride it as cook-book medicine run by technical managers interfering in clinical work. Obviously the ignorant will be prone to say what they want, that will be a reason to work to remove the ignorance not to forget the observed truth, unlike conventional healthcare practices and religion with its believed truth, this method is really the observed and demonstrated truth. Of course if you decide to choose conventional scientific research as a career then these methods are not suitable for you but if your life is that of a normal operational clinician then these are entirely relevant. I do not expect you to understand the new method fully, it will be a reason to learn it in due course. Enough for now to be aware that there are plenty of problems and there are proven solutions – just a matter of putting them together at the right time.

The wrongness that exists in medicine will not go away, that can only be solved by scientific research and one day you may in your lifetime find that medicine is based purely on scientific evidence. Till that time, awareness of, learning and practising the shared baseline method will give you superior results despite the wrongness around you.

As you stand on the threshold of entering into a new world, I wish you every success and great happiness in the practise of your profession. There can of course be no greater professional joy for a doctor than to see more of their patients get better.

Affectionately

HEMADRI

August 2012

©M HEMADRI 

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