What did you just do, page 4
Tight protocols such as these cut down the risk of clinical error, but would universal protocols completely remove IA?
“You can make as many rules and regulations as you like, but unless you have a policeman on every doctor’s shoulder, you cannot force people to follow them,” says Toft. “More protocols are not the way forward as they overcomplicate the system.”
James Reason, Emeritus Professor of Psychology, extends Brian’s argument. He says that protocols need to be simple, so that they can be easily followed and understood. Too much focus on protocols will disengage clinicians and draw their attention away from common problems. He identified risks in protocols concerning wrong-site surgery.
- Written checklists are prone to skipped steps and inaccurate box ticking.
- Increased numbers of caregivers can cause routine violations of protocols.
- Stress and rushed conditions lead to breaches of checklists.
Medical systems
Protocols are ineffective unless they are understood by the people who are applying them.
Toft argues that we can tackle the gaps in existing protocols by understanding the theory behind medical systems.
IA is driven by systems and operational environments, so if a manager of a department is warned that a person could be caught by IA and does nothing about it, then should a patient safety incident occur, then they, not the doctor, should be held accountable, says Toft.
In his report on IVF mistakes at Leeds Teaching Hospitals, Toft flags up a letter written to a senior manager from an embryologist who anticipated an error in the IVF department because the workloads were too high. A week later the wrong sperm was used to fertilise an egg.
“Why should an embryologist be professionally destroyed because management cannot change the work schedules to stop this from happening?” contends Toft.
IA could turn conventional ways of looking at clinical negligence claims upside down. Instead of a clinician being held accountable for causing an iatrogenic injury, the manager and working environment could be held responsible. Toft says he tested this argument with a number of legal authorities and no obvious flaws were pointed out that would cause it to fail.
Issues for the future
The theory of involuntary automaticity poses important questions about the way patient safety can be improved. Developing rigid rules and protocols is not enough – these systems must make the most of the strengths and take into account the weaknesses of the humans in the machine.
Brian Toft is currently working on his second paper on involuntary automaticity as a legal defence.
Avoid involuntary automaticity by:
- Teaching doctors about systems theory
- Adapting protocols to generate tactile and oral responses
- Creating effective relationships between managers and clinicians
- Using independent checkers
- Developing different checklists to keep clinicians alert
- Involving patients in their consultations more effectively
- Minimising stress levels
- Reducing distractions