By Benjamin E. Ruark
The focus of this article is on human error—lapses and slip-ups—triggered by situational factors such as distractions, multitasking, daydreaming, fatigue, stress, and interruptions. Healthcare organizations apply various remedies to minimize or mitigate errors, which nonetheless still occur, sometimes with grave consequences. But what if we’re taking the wrong approach to error prevention? What if procedural lapses and slip-ups were biologically more likely based on how areas in the brain function—specifically, how those areas function with reference to performing routine procedures? What if human error in routine procedures was predicated on competing areas in the brain, with a less-suited function recurrently suppressing a better-suited one? Not only is that the veritable case, an approach is suggested for turning tables on these two competing functions.
Before detailing the current procedural dilemma, here is a sampling of errors that healthcare workers of all organizational levels may succumb to when distracted or interrupted:
- Failing to realize a resource needed to perform a procedure is missing
- Making a wrong decision about which alternative action to take
- Misinterpreting the meaning of an unfamiliar instruction or a detail about a patient
- Omitting a step from a procedure due to forgetting or changing the procedure’s order of steps
- Performing a procedure on the wrong limb, wrong site, or wrong patient
- Taking too long to execute or poorly timing the performance of a procedure
Some organizations resort to policies or performance checklists to discourage distractions and interruptions, but these interventions seldom attain acceptable compliance. Moreover, multitasking and daydreaming are just as likely, if not more so, to cause human error. The first order of change is to shift the performance standard in the right direction: toward each patient’s best interests. And to do that—to learn what best serves a particular patient—the person performing a mundane procedure must literally shift brain regions.
Let’s briefly look at some of the brain’s anatomy. The basal ganglia (BG), a set of brain structures located beneath the cerebral cortex, are responsible for our learning of repetitive tasks. Over time, recall of the repetitions grows stronger and gets stored. This type of memory has a name: habit memory (or motor memory). In the workplace, we reference each other’s performance of routine procedures (of all kinds) as being on “automatic pilot.” That’s because we aren’t as acutely focused when doing those procedures; we’re performing by rote and may be thinking of other things (daydreaming). Habit memory is basically a subconscious function. Some examples of the BG being in play are riding a bike, walking on familiar pathways, and driving to/from work (and perhaps daydreaming en route). Skiing, swimming, and tying one’s shoes are still more examples.
The hippocampus (HC) assists with memorization of events and facts that may have future importance. Where procedures are concerned, it joins with the executive function, the prefrontal cortex (PFC), to consciously perform new and nonroutine tasks. The PFC (aka the “command center”) is located in the frontal lobe of the brain, directly behind the forehead. It is where conscious thought and behavior originate. In its charge are working memory, decision-making, focused attention (staying on task), shifting attention, formulating future plans and strategies, controlling impulses, modulating intense emotions, and more. Cognitive scientists call memory associated with these future-based activities prospective memory.
When learning a new task, a worker must consciously attend to its details, using working memory, to learn (encode), make decisions, etc. as the performance progresses. However, once a task has been learned through repetition, the worker’s conscious PFC-HC system is then suppressed by the BG, which faithfully take over the performance of that learned task. A common example is driving home from work, but planning (PFC) to add a quick stop at the store. En route, the driver’s subconscious BG take over, the drive being an established routine; the PFC-HC is suppressed while the driver is daydreaming or watching the sights. Before long, the driver is arriving at home, suddenly realizing the stop at the store never happened. Another way this occurs is when the drive home is highly stressful. In this case, the amygdala, which processes and stores memories of emotions and stress-provoking events, will also help suppress PFC-HC attention on the present, with the same outcome: a forgotten stop.
Missing the trip to the store is a minor inconvenience (as is forgetting to take the cup of coffee off the roof of the car in the morning rush), but such errors in routine tasks can have grave consequences. Examples of human error in healthcare include amputating the wrong limb, leaving sponges or surgical devices inside a patient, dispensing the incorrect dosage or type of medication, or misinterpreting a symptom’s cause and hence recommending the wrong intervention. Some non-healthcare examples include children and service dogs left in the back seat of hot vehicles and dying from heatstroke, airline pilots forgetting to set the wing flaps before landing, and police officers leaving their guns and ammo belts in public restroom toilet stalls.
In short, while routine service tasks may lead to acceptable human errors in many industries, those same errors should be considered flatly unacceptable in healthcare. Allowance of error when it can be better controlled for threatens the “do no harm” principle. With this in mind, caregivers’ PFC function must be made to take priority even in the most routine procedures, not just the surgical ones. In other words, suppressing the BG in nearly all instances would better serve as the rule. This novel approach for performing routine procedures has been demonstrated in a skilled nursing facility, but this article keeps the language general to ensure universal applicability across healthcare settings.
Ensuring PFC dominance in even the most basic procedures will result in higher engagement of workers at all levels of care. With their prospective memory system more frequently activated, workers will consciously engage their attention, decision-making, planning, reflective thought, and working memory almost routinely, rather than sparsely. This is a boon for patients. Fewer errors will occur from performance lapses and slips. Distractions, interruptions, and multitasking will still occur, of course, but when they do, the worker only needs to return to the first of three salient questions to be asked of every patient before performing a routine task.
Before we discuss those questions, a definition of item is necessary. As used here, an item, or “X,” is anything applied to, delivered to, or consumed by a patient (e.g., a bandage, a cup of tea, gauze, medication, etc.). Moreover, an item can also be a part of the patient’s anatomy (arm, finger, scalp, etc.) or the patient in general (for example, when a routine task simply involves speaking to the patient about something).
We must also consider an added dimension to completing each routine task. A majority of routine procedures traditionally have only one performance standard: whether or not they were completed. Other procedures may specify a quantity, as in a dose of medication. Regardless, in this new approach, we add another standard: whatever it is about that particular procedure that optimizes it to best serve the individual patient.
So, the three salient questions the healthcare worker should ask are:
- What is the item (X) this procedure focuses directly on?
- What optimizes X for this particular patient? The patient may have an appropriate answer; regardless, the worker also needs to supply an accurate answer to this question. These answers should be merged into a single definition of optimized that best serves this patient.
- Based on this knowledge, how do I optimize X for this patient?
Let’s say the healthcare worker is tasked with informing the patient and family of a diagnosis, based on test results. The worker first acknowledges that X is the patient and family. Awkward as it may seem, the worker might then ask the group if they have any preferences about hearing mixed or bad news (optimizing). The patient and family might say, “Please soften it, but don’t hold anything back” or something similar. So, the worker’s attempt to optimize the procedure might be: “While the test results I’m going to explain to you are not good news, our findings point to several treatment interventions of varying efficacy, which is very promising. There’s much here to be hopeful about. Now, about those test results …”
PFC-activated service performers will not perform any routine procedure on autopilot. They’ll be more alert for anything that may need further probing in terms of possible influence on a procedure or its output. The kinds of salient things that may have high probability of relevance and influence are:
- Procedural context
- Patient’s perception (as indicated by telltale reactions) and voiced expectations
- Individual differences
- Prior history
- Near-term/long-term impact from the performance of the procedure or from its output (e.g., site infection from an unclean injection site)
Some readers may wonder whether, over time, the strategy described here will itself become a routine, rote procedure. Will workers become just as vulnerable to the same species of human error as they continue to get distracted and interrupted? The answer is no—not if they stay engaged by asking for their patients’ input, and by asking themselves the three salient questions. If they take shortcuts and merely guess at what will optimize X for any patient encountered, then they’ll be more or less operating on autopilot once again.
Psychologically, there are some incentives for staying PFC-HC engaged in the performance of routine tasks. First, while asking the same three salient questions is in itself a routine, the answers to the questions are not: The planning, decision-making, and tapping into working memory all demand executive function—the PFC—to make things happen. Second, dopamine and oxytocin are likely released from close and protracted interaction with patients. They comprise two of the so-called “feel-good” hormones and contribute to enhanced learning. Third, there’s a likelihood of positive reinforcement of PFC engagement (instrumental conditioning) due to the innovating of repeatedly optimized procedures. All signs of effective healthcare delivery now point to greater application of more deliberate and critical thinking.
Adopting this new approach toward optimizing even the most routine of procedures will benefit everyone through higher quality and reduced chances for human error. It will, however belatedly, replace the misapplication of habit memory (BG) with its more effective peer (PFC) by activating conscious thought in routine healthcare procedures.
Benjamin E. Ruark is a former learning & development and Continuous Quality Improvement professional who now devotes his time to writing about important subjects for various industries, including healthcare.