Transcript presentation ( format)

Making Changes to Avoid Repeat Errors:
How Cognitive Psychology Can Help Us
Eleanor W Davidson MD
Sara H Lee MD
Our backgrounds
Sara Lee
Pediatrics, Adolescent Medicine
Faculty, Rainbow Babies and Children’s Hospital
Nell Davidson
Internal Medicine
Clinical Faculty, Department of Medicine
The event that led to this presentation
18 year old first year student has flavored coffee &
fruit at campus food outlet
Symptoms at emergency room included difficulty
breathing, wheezing, facial swelling
History of anaphylaxis at age 12, “aviary pavilion”
Has epipen but not with her
Also an anxiety disorder
No information on day of event (Monday)
Wed: nurse director receives phone call from mother
of student.
President of university also receives complaint from
mother.
President puts together a team to analyze what
happened & respond
Incident Report: Essential elements
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Executive summary
Background
Initial analysis
Investigative procedures
Finding(s)
Recommendations
Staff member performing investigation
Executive summary
Overview of the incident
Estimate risk level (high, medium, low)
Determine if risk has been contained
Once these steps have been completed,
you can continue with root cause
analysis of the event.
Root cause analysis
An opportunity to involve your whole team in a
Critical Safety Analysis process:
From “Failure Mode Effect Analysis” in the US
Military
This also derives from a presentation by Edward J
Dunn MD MPH and Craig Renner MPH (VA
National Center for Patient Safety)
Root cause analysis
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A tool in the systems approach to prevention
NOT punishment
Helps build a culture of safety
A process for identifying contributing causes
A process for identifying what can be done to
prevent recurrences
• A process for measuring and tracking outcomes
When is RCA done?
For any adverse event or close call.
For all JCAHO designated “sentinel events”
Root cause analysis
What happened? (event or close call)
• What happened that day?
• What usually happens? (norms)
• What should have happened? (policies)
Root cause analysis
Why did it happen?
What are we going to do to prevent it from happening
again?
Actions, outcomes
How will we know that our actions improved patient
safety?
Measures, tracking
Similar to the foundations of current “best practice”
CME:
1. Identify the “practice gap” (difference between
current practice and idealized/achievable practice).
2. Identify what factors are at work, causing that gap.
3. Devise strategies to eliminate the practice gap
Strategies
Strategies are:
1. Actions we take to prevent the error from
happening again.
2. Actions that include outcome measures so we
can test their effectiveness.
“Hoping for the best” and “trying harder” are
not strategies.
Testing the action steps
1. Create action with measurable outcomes
2. Test in PDSA cycles
3. Evaluate whether change caused improvement (or
simply change)
4. Create additional action steps to test
PDSA Cycles
Our initial analysis
What happened that day?
What usually happens?
What should have happened?
Initial questions
Did clinicians not recognize anaphylaxis?
Did they recognize it but were hesitant to treat:
Unsure about dose of epinephrine?
Unsure about safety of epinephrine?
Unsure if beginning treatment meant you had to
keep patient there?
Do pediatricians have different experience-base than
internists?
How does that affect treatment choices?
Do we train clinicians well enough in “urgent care?”
Anaphylaxis in Adolescents and Young Adults
Anaphylaxis
Acute allergic reaction involving 2 or more organ
systems or hypotension alone
“. . . potentially life-threatening event that requires
vigilance on the part of the healthcare practitioner
who needs to recognize the condition quickly and
initiate early treatment” (Linton E, Watson D. Recognition, assessment and management of
anaphylaxis. Nurs Stand. 2010 Jul 21-27;24(46):35-9.)
Exaggerated response to an allergen
What causes anaphylaxis?
3% of teenagers have food allergies (may be as high
as 4-8%), and Number is increasing
Anaphylaxis may also be increasing – Pediatric ED
visits for food-induced anaphylaxis doubled from
2001 to 2006 in one study
Usually triggered by food, insect stings, or
medications
IgE mediated or other immunologic mechanisms
How does anaphylaxis present?
• General
Anxiety, weakness, malaise
• Respiratory
Wheezing, difficulty breathing,
throat constriction, stridor
• Dermatologic
Eye redness, lid swelling
Swelling of tongue and lips
Rash, itching, flushing
• Gastrointestinal
Nausea, vomiting, diarrhea,
abdominal cramps
• Cardiovascular
Tachycardia, hypotension
• Neurologic
Headache, dizziness, confusion
Clinical Criteria for Diagnosing Anaphylaxis
Adapted from Sampson HA, Munoz-Furlong A, Campbell RL, et al. Second symposium on the definition and
management of anaphylaxis: summary report – Second National Institute of Allergy and Infectious Disease/Food Allergy
and Anaphylaxis Network Symposium. Ann Emerg Med. 2006;47:373-80.
Why does anaphylaxis get missed?
Anaphylaxis is under-recognized
Clinicians may miss anaphylaxis for a number of
reasons
No exposure to typical offending agent
Varied and atypical features
No lab tests
Differential includes anxiety, vocal cord dysfunction,
vasovagal reaction, panic attacks
Is anaphylaxis in college students more likely to be
missed?
Adolescents and young adults appear to be at increased risk for
fatal food allergic reactions
Less parental oversight
Increased risk-taking
College students
Are unaware of the symptoms of anaphylaxis
Have low reported maintenance of any emergency medication
Do not tell close campus contacts, campus health services, or
dining services
Willingly ingest self-identified food allergen (particularly those
who have not experienced anaphylactic symptoms)
Management of anaphylaxis
Assessment
Airway – speaking sentences, stridor, wheezing
Breathing – RR, work of breathing
Circulation – P, BP, cap refill
Disability – consciousness
Exposure – rashes
Management of anaphylaxis
Administer IM epinephrine every 5 to 15 minutes until appropriate
response is achieved using:
*Commercial autoinjector*
0.3 mg for patients who weigh more than 66 lb
0.15 mg for patients who weigh less than 66 lb
Or
Vial 0.01 mg per kg with a maximal dose 0.5 mg in adults
Call 911 or Rescue Squad
www.immunize.org
Epinephrine is essential
Alpha-1 adrenergic agonist vasoconstrictor effects
prevent and relieve laryngeal edema, hypotension,
and shock
Delayed epinephrine is associated with increased risk
of fatal reaction
Epinephrine is essential – but providers and patients
do not use it
Epinephrine is used infrequently in emergency
settings
Despite universal recommendations for the use of
epinephrine in anaphylaxis, it is uncommonly used
by patients and providers
Symptoms perceived as not severe enough
Perceived as dangerous
Epinephrine effects
Expected:
Anxiety, headache, dizziness, palpitations, pallor,
tremor
Rare:
Arrhythmias, myocardial infarction, pulmonary
edema, intracranial hemorrhage
There are no absolute contraindications to
epinephrine in anaphylaxis
Perceptions of epinephrine safety – does it vary by
specialty training?
Pediatricians need to use epinephrine for airway and
breathing
Internists and Family Medicine physicians need to
worry about the effect of epinephrine on the heart
Heart is a target organ during anaphylaxis
Risk of death from anaphylaxis outweighs other
concerns
Additional problems
How do clinicians conceptualize their job?
Whose responsibility is it to manage the unscheduled
person who walks into your Health Service?
What happens at times when fewer staff are on duty
or newer staff only? What are the predictable times
when errors with occur?
Do you have other thoughts?
Transportation?
Would patient education help?
Would parent education help?
I was still puzzled.
Lessons from cognitive psychology
Cognitive psychology is the science that
examines how people:
• reason
• formulate judgments
• make decisions
Donald Redelmeier MD
The cognitive psychology of missed diagnoses.
Annals of Intern Med 2005; 142: 115-120
Why is it a science?
The term “science” implies that cognitive errors may
be predictable in some situations—not the result of
ignorance or the acts of a few bad performers.
Can we use this science to improve our practice?
- understand how errors are made
- take corrective action to avoid them
- become more aware of the errors we make all the
time, based on incorrect assumptions
The Invisible Gorilla: How Our Intuitions Deceive
Us (Christopher Chabris and Daniel Simons)
We all believe that we are capable of seeing what’s in
front of us:
-accurately remembering important events from our
past,
- understanding the limits of our knowledge,
- properly determining cause and effect.
But these intuitive beliefs are often mistaken ones that mask
critically important limitations on our cognitive abilities.
Examples
The nuclear submarine and the fishing boat
• what the captain thought he’d see when he looked;
• we’re only aware of a small portion of our visual
world at any moment
• we can look, but not see
Ben Roethlisberger and the left turn:
• Car drivers don’t see the motorcycle because
they’re not looking for them—motorcycles are
unexpected (they assume they will notice, however)
• Raising awareness with signs won’t help, except for
short periods of time (cf CME)
• Wearing conspicuous clothing? When something is
unexpected, distinctiveness does not guarantee
that we will notice it (won’t override our
expectations)
What might help?
Make it look more like something expected
Make the event less “unexpected” (annual
reviews/drills)
(Bike riding is safer in cities where it is more common)
Cell phones
“Most people believe that as long as their eyes are on
the road and their hands are on the wheel, they will
see and react appropriately to any contingency.”
But…”experimental and epidemiological studies show
that the driving impairments caused by talking on a
cell phone are comparable to the effects of driving
while legally intoxicated.”
The problem is not that that there are limits on
attention; the problem is our mistaken beliefs
about our attention.
“Even when we know how our beliefs and intuitions
are flawed, they remain stubbornly resistant to
change.”
Not a problem with our eyes or hands.
A problem with “consuming a limited cognitive
resource”
What would it mean to behave as though our attention
is not boundless?
What strategies do you employ to focus the attention
of your staff at work?
References
Arnold JJ, Williams PM. Anaphylaxis: recognition and management. Am Fam Physician. 2011 Nov 15;84(10):1111-8.
Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Atkinson W, Wolfe S,
Hamborsky, J, eds. 12th ed. Washington DC: Public Health Foundation, 2011.
Greenhawt MJ, Singer AM, Baptist AP. Food allergy and food allergy attitudes among college students. J Allergy Clin Immunol.
2009 Aug;124(2):323-7.
Keet C. Recognition and management of food-induced anaphylaxis. Pediatr Clin North Am. 2011 Apr;58(2):377-88.
Lack G. Clinical practice. Food allergy. N Engl J Med. 2008 Sep 18;359(12):1252-60.
Linton E, Watson D. Recognition, assessment and management of anaphylaxis. Nurs Stand. 2010 Jul 21-27;24(46):35-9.
Rudders SA, Banerji A, Vassallo MF, Clark S, Camargo CA Jr. Trends in pediatric emergency department visits for food-induced
anaphylaxis. J Allergy Clin Immunol. 2010 Aug;126(2):385-8.
Sampson MA, Muñoz-Furlong A, Sicherer SH. Risk-taking and coping strategies of adolescents and young adults with food allergy.
J Allergy Clin Immunol. 2006 Jun;117(6):1440-5.
Additional Resources
Food Allergy and Anaphylaxis Network’s College Network (www.faancollegenetwork.org)
National Institute of Allergy and Infectious Disease (www.niaid.nih.gov)
www.theinvisiblegorilla.com
www.beingwrongbook.com