The "Why" of Error in Clinical Systems

Marilyn Sue Bogner, Ph.D.*

Institute for the Study of Medical Error

9322 Friars Rd, Bethesda, MD 20817

Ph. +1 301.571.0078

Fax: +1 301.530.0679


Adverse outcomes associated with presumed human error increasingly are receiving media attention with concomitant increased clinical concern, emphasis on reporting errors, and pressure to reduce the incidence of such events. The emphasis of error reporting systems is on the error or event which typically is identified through an associated adverse outcome of death or serious injury, and attributed solely to the care provider involved in the event. Although such attribution satisfies the need to explain the event and provides the clinician as a target for remedial action such as training, those actions seldom solve the problem. This presentation discusses an approach to identify factors other than the clinician that lead to error. Those are factors inherent in the systems that comprise the context in which care is provided.

The purpose of this presentation is to underscore the value of the systems approach in reducing the likelihood of human error in health care. First the systems approach and its application to error via heuristic incident reporting will be described with emphasis on how that approach changes the manner by which error is reported. Next, examples of heuristic incident reports are discussed. Finally, implications of the systems approach and heuristic incident reporting to error management and reduction are addressed. It is to be noted that this presentation proposes the systems approach to error management as central to quality health care.

Obtaining information for studying error is hindered by the specter of litigation. The presumption is that the care provider associated with an error was negligent; however, studies by several industries report that error is not the result of a single act, but is precipitated by the co- occurrence of a number of conditions or precursor mini-errors each of which is necessary, but not sufficient for the incident. Research in several domains has found these conditions and precursor events to be influenced by numerous interacting systems or categories of factors.

The immediate context in which health care is provided is impacted by a number of interacting systems ranging from the systems of laws, regulations, and cultural mores, through the organization system, the social system, the physical system, and the system of ambient conditions to the care providing system. The latter system contains three entities or subsystems: the care provider, the means for providing care which include medical devices and procedures, and the recipient of care, the patient. These systems can be conceptualized as concentric circles or layers of an onion from the most distal of the cultural mores to the most proximal to the nucleus of the care providing system.

Despite the findings that errors are the culmination of a cascade of mini-errors which may not have direct adverse outcomes, most error reporting systems focus on describing the specific incident, the error, often reported only when associated with an adverse outcome. Some incident reporting systems such as the Aviation Safety Reporting System (ASRS) provide the opportunity for individuals to describe a near-miss incident or an event in their own words. Such reporting can include distal system factors that contributed to the near-miss or incident, but no memory aides per se are provided. It is acknowledged that some ASRS data entry personnel may probe for additional information, but that is inconsistent. The ASRS raises 3 issues: the value of reporting near-miss incidents as well as events, the importance of those involved in the incident describing it in their own terms, and the utility of eliciting relevant systems factors. The heuristic incident reporting described in this presentation incorporates these three issues.

Health care providers are trained to be responsible which includes being responsible for adverse event. Because of this, providers tend not to consider system factors as contributing to the adverse event, a near miss incident, or an event waiting to happen. The heuristic reporting asks that each of those three types of incidents be described and aids the reporter in recalling factors that contributed to the incident by presenting a list of the systems comprising the context of care. As a quality assurance activity, the reporter is encouraged to note at least one potential factor for each system. Analysis of responses by type of incident as well as across incidents indicate system factors to be addressed to manage error and enhance quality of care. Examples heuristic reports and analysis of the reports will be presented.

The value the heuristic incident reporting is threefold. First, reporting near-miss incidents and events waiting to happen provides information to determine the "why" of error as well as adverse events. This could result in system change that avoids adverse outcomes. Secondly, repeated use of this heuristic incident reporting orients the focus and judgement to the system rather than the provider, and because the onus of presumed guilt is reduced through consideration of system factors, there is an impetus to report adverse events. Thirdly, reporting information by system factors enhances quality of care by identifying issues to be addressed by the appropriate aspect of the system which provides a target for follow-up evaluation. Thus, rather than punishing the individual without concern for the context hence perpetuating the existence of factors that contribute to adverse events and compromise quality of care, heuristic incident reporting focuses the search for the "why"of the error or incident to system factors such as equipment design, excessive workload, and reimbursement policies. Addressing the identified system factors reduces the likelihood of subsequent events and adverse outcomes for all health care providers and enhances quality of care and patient safety. .