3 surprising links to medical errors

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To err is human, and in the health care arena, avoiding errors is crucial. Efforts to address communication-related or “soft skill” failures have been ongoing since about 20 years ago when the Institute of Medicine (IOM) published reports titled To Err Is Human and Crossing the Quality Chasm. When we rely on extrinsic approaches to reducing human errors — such as using only color-tinted intravenous tubing or keeping detailed checklists — it’s harder for us to make mistakes. Such human interactive skills, also discussed at length in Successful Nurse Communication, a 2015 book by Beth Boynton, are linked to patient safety, patient experience, and workforce health. But, while extrinsic approaches to controlling human behavior are essential, we should also consider intrinsic approaches that prepare health care professionals to optimize their own behavior.

In order to appreciate how important this concept is, a basic understanding of complex adaptive systems (CASs) is required. CASs are made up of elements that are interconnected and able to respond to change in varied ways. A flock of birds is a good example of a CAS. Consider a flock flying towards a feeding area or away from danger. Moving as a group, the individuals respond to the environment in the moment, and the flock appears fluid. No one is telling each bird where or how fast to go, and they did not attend an in-service to prepare for changes in wind velocity. Instead, they are following a few simple rules that guide their relationships, such as maintaining distance from each other and matching speed with their neighbors. They also share common goals, e.g., finding food or safety.

In a health care workplace, all participants also share a common goal: making sure patients receive the quality care they deserve. There are seven primary properties of CASs that are closely related to the soft skills that are important in such a setting, and we will discuss three of them here: adaptability, the butterfly effect, and emergent behavior.

Adaptability

Adaptability refers to the ability of the participants to adapt and learn from changes in their environment. In a high-stakes, high-stress health care environment, we could not be adaptible without consistent, effective and respectful communication.

For example, inviting input on an issue and listening to it is key for engaging staff. Leaders sometimes avoid such engagement, because they assume that staff will expect them to follow all recommendations, which could lead to conflict if they don’t. Instead of validating, considering input and setting limits, they simply avoid asking. Staff who don’t feel heard may become disengaged or use resistance to solutions (consciously or subconsciously) as a passive-aggressive way of being heard. Whereas, many people will accept reasonable limits if they feel heard.

Leaders can also embrace this idea to increase staff accountability for stubborn problems like, for instance, hospital-acquired infections. By asking staff, “What do you need to comply with hand-washing protocols?” and then listening carefully to the responses, they create the conditions for learning new information that might help, and they relay the message that input is valued.

The butterfly effect

The butterfly effect refers to a small event happening in one place, like a butterfly flapping its wings contributing to a large event happening someplace far away, such as a hurricane on the opposite side of the world. The butterfly effect of disrespectful versus respectful communication can be seen in these two health care-related examples:

  • A doctor yells at a nurse on Tuesday. On Saturday, she hesitates to call him to report a subtle change in a patient’s condition. Instead, she reports her concern to the oncoming nurse, who makes it a priority to check this patient, but the telemetry alarm beats him to it. The patient dies.
  • Nurse A overhears Nurse B talking about her in a negative way and interrupts the conversation. “I’d appreciate it if you have concerns about my work that you discuss them with me directly.” Nurse B apologizes and later helps Nurse A get pain medication to her post-op patient quickly. The patient and his wife feel cared for. The patient experience scores improve.

Emergent behavior

Emergent behavior refers to how we behave in the moment and in relationship to others. To gossip or not, to offer or take in constructive feedback versus avoiding conflict, or to speak up or remain silent about a concern are soft skills that are intrinsic in each of these behaviors:

  • The nurse assistant who went in and held a patient’s hand in the middle of the night when she sensed the patient was anxious.
  • The surgeon who tells the OR team she expects each of them to watch for and report problems.
  • The social worker who reminds the unit coordinator that computer system is going to be down during the evening shift.
  • The nurse leader who negotiates budget allocations for delegation skill training for nursing staff and a part-time nurse assistant during the busiest times.
  • The housekeeper who shares her insight with the clinical team that a post-op patient’s fear of falling was the reason she was afraid to walk with the physical therapist.

Conclusion

These soft skills and how they relate to outcomes in health care may be hard to see, but now that you know how to look for them, you’ll spot them more easily. As you do, you may see or suspect their impact in the workplace. Did the nurse who hurt her back ask for help? Was the surgeon receptive to challenges during the wrong-site surgery? Would the resident have fallen if the nurse assistant sat with her for a few minutes and listened to her concerns?

Hard-to-measure yet critical, healthy soft skills can improve the care we give to our patients, the workplace culture and the rewards of our important work in the health care industry.

Beth Boynton is a writer, Careers by KevinMD.com

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