“In one study, 70%


of surgeons said that fatigue doesn’t impact their performance. But we know that’s not true.” —NOOR AHMAD, MD


The person who has just made a mistake does not need punitive action focused on what went wrong, Dr. Ahmed said. “That physician will remember the mistake forever. They need support, not condemnation.”


He shared an example of a physician who had an adverse event after using the wrong catheter. A reactive solution would be to tell the physician to pay more attention. But instead, the case was reviewed and investigators found that the intended catheter and the one actually used had similar brand names. As a result, the staff made a system change and took out brand names to avoid future error. In addition, they saw an opportunity for creating another step in the process for catheter verification.


“You have to look at how humans interact with systems and take into account human characteristics,” Dr. Ahmed said.


Medical workers tend to lack the ability to be self-critical, Dr. Ahmed says, either due to ego or fear—which leads to poor communication and inaccurate reporting.


“In one study, 70% of surgeons said that fatigue doesn’t impact their performance,” Dr. Ahmed said. “But we know that’s not true.” External factors like noise, light and distractions, and internal factors like stress, fatigue, hunger


34 IRQ | SPRING 2023


or illness all play a part in creating errors and can happen to anyone.


Using the example of a delayed diagnosis of an aortic dissection, Dr. Higgins explained how many different internal and external factors can lead to an error.


“Through a route cause analysis, we found that the emergency department was unusually busy that day, and the ultrasound wasn’t working. The provider was on their third night shift in a row and was fatigued. The intern was on her first day and felt hesitant making decisions. The patient was also aggressive and difficult to deal with. And at this particular institution, there is an unspoken rule that you don’t call others for help, as everyone is busy trying to keep their heads above water and care for their own patients,” said Dr. Higgins. “The outcome of any of these situations was that the patient had a delayed diagnosis of a thoracic aortic dissection that could have been treated, and as a result, the patient sadly expired while awaiting care.”


So how does this facility learn from this patient’s death and move forward?


A culture of safety Building a culture of safety requires utilizing data and respectful discussions to identify the root cause of an adverse event, and then adjust accordingly, Dr. Ahmed said.


He suggests using a safety event review tool to walk through each aspect of the complication or event. Did it meet the standard of care? If you substituted another provider, would they make the same mistake? Did the provider intend to make the mistake? According to Dr. Ahmed, if the answer to substitution is “yes,” then the provider needs coaching—not punitive action.


Supporting a culture of respectful interviews and data collection, where that data leads to demonstrated improvement, makes it easier to avoid complications, he said. Tracking tools such as standardized templates, review panels like morbidity and mortality conferences, and project management approaches like the LEAN or A3 methods can identify problems, review the root causes, and put systems in place to create better results.


Establishing a peer-review process is another way to track complications, regardless of practice size.


“In academics, the peer review process is often focused on training,” said Hector Ferral, MD, FSIR. “But in private practice, any complication may become a legal problem. A documented peer review process can help prove lack of negligence.”


Dr. Ferral’s practice has instituted a peer review process and conducts review sessions monthly. These cases are selected by attendings and residents, and they discuss adverse events, communication issues and “near misses.”


The group reviews imaging, discusses and classifies the adverse events, and reviews literature to determine if they need to change practice patterns. Sometimes these changes are broad, such as when they reviewed the case of a PE patient who had a negative outcome. After discussion, staff agreed to create a PE response team, revised their anesthesia protocols and improved practice patterns.


Better experience While a quality and safety culture improves patient outcomes, it should also improve the overall patient experience.


Joshua Weintraub, MD, FSIR, shared his experience trying to improve start times at his facility.


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