JoHo

What are absent-minded errors?

On an afternoon in 1970 James Reason was boiling some water for a cup of tea, while his teapot was waiting for the water and for the tealeaves. His cat was meowing for his food, and because Reason was a little scared of his cat he decided to feed the cat first. But instead of spooning the cat food in the cat’s bowl, he spooned the food into his teapot.

This slip had a number of interesting properties. Giving the cat his food and setting some tea are both highly automatic, habitual sequences that he did in a very familiar environment (his home). The meowing of the cat did not usually occur, this captured the attention and lead to the slip. This slip seemed to have nearly all the principal characteristics of absent-minded errors:

• Both acts (tea, food) were highly routine, so attention was absent.
• Both the cat’s bowl and the teapot afforded containment.
• There was a change in the routine sequence (meowing) that misdirected the action.

Another example for this kind of slips was when Reason observed his wife making tea. His wife was boiling water and had the teapot open waiting for the water and the tealeaves. But instead of getting tealeaves she reached for the jar of coffee, put some spoons into the pot and added water. Only when the strong smell of coffee came, she noticed the slip. The thing of importance is the way she put the coffee into the pot. James explained that the tealeaves have a pull-off lit and the coffee has to be unscrewed. He came to the conclusion that well-used familiar objects develop a local control zone. This means that when your hand enters the zone (like close to the fruit bowl) is automatically performs an object-appropriate action (pick up an apple).

Aimless periods, like passing the time waiting on a phone call, show us that a lot of our behaviour is under the control of the environment, which in turn leads to unintended actions.

What are strong-habit-intrusions?

Strong-habit-intrusions are actions that are under-specified (due to forgetting, reduced intention etc.), people tend to lean on the actions that usually occur in that particular context. These situations are called strong-habit-intrusions.

The tip-of-the-tongue phenomenon is a state where strong-habit-intrusions occur. We struggle to retrieve the word that we mean, but we can recall all the words that seem similar to it (blockers).

This chapter distinguishes three types of performance levels. Slips and mistakes arise from different mechanisms. Slips from failures in execution (often occurring because of automatic procedural routines also called action schemas) and mistakes from failures in planning. There is a problem in this categorization because some errors possess properties from both.

Which errors?

Two big errors that illustrate a combination of slips and mistakes

Oyster Creek: The annulus level and the water level are usually the same, but this time they weren’t. They mistook the annulus level for the water level, which was very close to the fuel elements. Even though an alarmed sound 3 minutes after the error, it was not discovered until 30 minutes later.

Three Mile Island: The operators did not notice that a switch of the pressurizer was open; the panel light showed that it was closed. They only looked at the panel and did not think about the switch being broken or stuck.

The wrong appraisal of the system state looks like the property of a mistake, and the selection of the strong-but-wrong interpretations are more close to a slip-like failure. These type of error can be categorized as an inappropriate diagnostic rule, specifically the If (situation X prevails) then (system state Y exists) kind.

Using the by Jens Rasmussen distinguished three performance levels; skill-based (SB), rule-based (RB) and knowledge-based (KB). Using these three levels, there are three distinct error types created: skill-based slips, rule-based mistakes, knowledge-based mistakes.

How can we distinguish the performance levels?

The core distinction is whether or not the actor was engaged in problem solving. Skill-Based (SB) level involves no awareness of the current problem and is completely automatic and habitual. Routine-Based (RB) and Knowledge-Based (KB) are only triggered when the actor is aware of the problem he/she is facing. When the problem has an accessible solution it works on the RB level, but when it is harder to form is work in the KB level. When the problem is unfamiliar it is usually dealt with by trail-and-error.

One feature of SB and RB mistakes it feed-forward control. When it is a feature of SB it is a performance based on feed-forward control and depends upon a very flexible and efficient dynamic internal world model. When it is a feature of RB it is a performance that is goal-oriented, but structured by feed-forward control through a stored problem- solving rule. In may look like: If (X, Y, and Z are present) then it is (a B situation) or If (A) then (do C).

Control at KB level is mostly through feedback. This is necessary because at the KB level one can’t rely on their mental schemas and habituations anymore. It can be achieved by setting local goals, initiating actions to achieve these goals and then reflect if the action was successful or not.

There is a relationship between the predictability of error and the level of expertise. The more skilled an individual is, the more likely it is that their errors will take the strong-but-wrong form on a SB or RB level.

Humans are better at solving problems than computers. That is because if we exhaust our problem-solving skills we search for analogies that can help us solving the current problem.

The best example of coexistence of these three levels

Driving is the best example of the coexistence of the three levels. For example steering, changing gears and speed control are operated on a skill-based level. Dealing with other road users is an example of a rule-based operation and the knowledge-based level only shows if you for example unexpectedly have to change your route because of work on the road.

This chapter is about the Short Inventory of Minor Lapses (SIML), as self-report that estimates an individuals’ proneness to AM slips and lapses.

It is a 15-item questionnaire, as they are listed below:

• How often do you forget to say something you were going to mention?
• How often do you have the feeling that you should be doing something, either now or later, but you can’t remember what it was?
• How often do you find your mind continuing to dwell upon something that you would prefer not to think about?
• How often do you can’t remember what you have just done or where you have just been?
• How often do you leave some necessary step out of the task?
• How often do you find that you can’t immediately recall the name of a familiar person, place or object?
• How often do you think you’re paying attention to something when you’re actually not?
• How often do you have the ‘what-am-I-here-for’ feeling when you find you have forgotten what you came to do?
• How often do you find yourself repeating something you’ve already done or carrying out some unnecessary action?
• How often do you find you’ve forgotten to do something you intended to do?
• How often do you decide to do something and then find yourself side-tracked into doing something different?
• How often do you find yourself searching for something that you’ve just put down or are still carrying around with you?
• How often do you forget to do something that you were going to do after dealing with an unexpected interruption?
• How often do you find your mind wandering when you are doing something that needs your concentration?
• How often do you make errors in which you do the right actions but in relation to the wrong objects?

The most commonly occurring slips were: failing to recall a name, forgetting to say something, forgetting intentions and mind wandering.

How can age affect slips?

There are two explanations of the finding that self-reported incidents of minor slips and lapses diminished with age:

• The Activity Hypothesis: Old people are less active, and therefore have fewer opportunities to make AM errors.
• The Compensation Hypothesis: The first version of the hypothesis is that old people are aware of their diminished cognitive competence, and rely more on memory aids and reminders and therefor suffer less lapses. The second version (dread variant) is that older people might interpret slips and lapses as symptoms of dementia/Alzheimer and therefor spend more time and attention in their day-to-day performance.

This still doesn’t explain the big difference in results between ‘young’ (17-29) and ‘middle aged’ (30-49). Researches try to explain this by stating that same older people tend to ‘forget that they forgot’ or try to blame the difference on the way the questionnaire is build.

Can stress-vulnerability lead to cognitive failures?

A high level of cognitive failures and the number and degree of psychiatric symptoms experienced during or immediately following a period of real-life stress, is one of the most important findings of the questionnaire. Donald Broadbent argued that high rates of AM slips can lead to increased vulnerability to real-life stress.

To test this hypothesis, they gave woman who had breast cancer, the SIML and the Goldberg’s General Health Questionnaire. Results showed that the SIML correlated significantly with the number of psychiatric symptoms. They also found that depressed patients had higher SIML scores. On page 34 of the book (a life in error), you can find the list of all the predictors (e.g. radiotherapy, pain in scar).

The findings provide strong support for the stress-vulnerability hypothesis. One explanation for the underlying mechanism is that people differ characteristically in the way they develop. These differences lie in the way people cope with stress. For example, people who are error-prone use more resource-intensive strategies. It seems like stress is not the thing that induces the high rate of cognitive failure, but the way people deal with this stress.

Let’s start with what Freud actually wrote about slips and lapses: ‘A suppression of a previous intention to say something is the indispensable condition for the occurrence of a slip of the tongue’. So, a slip is a product of both local opportunity and a struggle between two mental forces: some underlying need or wish and the desire to keep it hidden. Freud also thought that every mistake we make has a meaning, even things as absent-mindedness and distraction.

Classic Example from Freud

In Freud’s book he describes a situation where he met a young man. The man tried to quote a line from Virgil, but didn’t do it accurately. When the young man noticed that he quoted the wrong line he wanted to explain to Freud why he did it wrong. After Freud quoted the right line he asked by the young man had forgotten the word ‘aliquis’ (someone). The young man explained that he was distracted because the words ‘a’ (fluid) and ‘liquis’ (saint of the blood). He told Freud that he was worried that his girlfriend didn’t got her period on time. This is exactly what Freud meant, there was an explanation for the mistake. Other researches don’t agree with Freud though and tried to explain the slip in various ways.

Another example from Freud

Another example of Freud was a story that his friend William Stekel told him. Stekel was saying goodbye to a patient of him at a house call. The extended his hand to the woman and discovered that instead of shaking her hand he was loosening her dressing gown. Freud explained this mistake as if Stekel has unconscious desires for this woman, but other explanations can be that he was so used to undoing bows of jackets and dresses for medical examination.

What are the conditions for provoking a AM error?

With these examples in mind, there are two necessary conditions for provoking a absent-minded error:

• Cognitive under-specification, inattention, incomplete sense of date or insufficient knowledge.
• The existence of some locally appropriate response pattern that is primed by prior usage or activation.

Freudian slips do occur, of course in some cases there is a reason behind a mistake. But they do not occur frequently. Everyday slips and lapses have more banal origins. For a slip to be Freudian, they have to be less familiar than the intended word or action. So the definition of slips from Freud that slips represent minor eruptions of unconscious processing, it true. But we don’t use the psychoanalytic meaning of unconscious, it as seen as not directly accessible, automatic.

A close examination of the behaviour of the operators during the Chernobyl disaster showed two distinct types of an unsafe act. First there was an unintended slip at the outset of the experiment, the reactor was operating at a too low power. The second act was that de operators decided to keep going with the trail. This example caused for a change in the way there was thought about his enquiries. The first focus was on individual error markers with a purely cognitive information-processing orientation and now they shifted more to an orientation that incorporates motivational, social and institutional factors. Errors can arise from informational problems in either the mind or in the environment. Violations are deliberate acts; people break the rules but people mostly don't intend the bad outcomes. Violations are mostly based on motivational factors: beliefs, attitudes and norms.

Violation Types

There are four types of violations:

• Corner-cutting or routine violations: Mostly committed to avoid unnecessary effort or to circumvent procedures. Most organizations have formal rules but also informal procedures (black book). The informal procedures are derived from skilled and experienced operators who recognize that formal rules are sometimes written without any expert knowledge. It would be best of the people who make the rules and the people who perform the procedures come together to create a workable set.
• Trill-seeking or optimizing violations: We have a lot of needs, which are often conflicting. Driving gives us a great visual of these needs; you want to get from A to B, but while you’re driving you enjoy speeding, like cutting in and may even start tailgating. Men and young people are more likely to violate, and it seems that women are not impressed by it so they act as a restraint on driver violations.
• Necessary violations: Many organizations as result of accidents continue to write additional procedures that aren’t necessary to get the job done. For the production of error is usually under-specification of the process, but with necessary violations it is over-specification. These violations to get to job done will become routine eventually.
• Exceptional violations: This type of violation is likely to occur under exceptional conditions. Because they occur infrequently, the operators are less practiced and the procedures often sparse.

What are ‘Mental Economics’ of Violating?

Petra Klumb investigated the costs and benefits of non-compliance. Error was more likely to occur when the benefits outweigh the costs. Examples of perceived benefits: easier way of working, saves time, gets the job done, looks cool and meets a deadline. Perceived costs can be: a possible accidents, injuries, damage to assets, costly repair, disapproval of friends.

Sometimes violations seem as an easier way of working with immediate benefits, the costs are mostly remote. To change this perception it is important to not increase the costs of non-compliance, but to promote the benefits of compliance.

Because of the many organizational accidents in the 1980s, the 1990s became the safety culture decade. Instead of focusing on the computer-based technologies (chemical processes, nuclear power etc.), the focus shifted to more traditional industries like infrastructure, mining and construction.

There are 3 ways in which a not accurately applied safety culture can negatively undermine a complex system’s protective layers (the slices of the Swiss Cheese Model):

• A poor safety culture will increase the number of defensive weaknesses caused by active failures (errors and violations). This will happen more in organizations that are neglectful in identifying error traps. The more dangerous thing is that a poor safety culture will also encourage an atmosphere of non-compliance.
• Inability to recognize and an inability to respect the operational hazards can lead to more long-lasting holes in the defensive layers. This can arise through underlying conditions during the maintenance, testing, adjustment, the wrong equipment or through downgrading the importance of training.
• The reluctance of an organization to deal proactively with their known deficiencies.

If there is one phrase that captures the essence of an unsafe culture it should be the unwarranted insouciance.

What Makes a Safe Culture?

Karl Weick says that the power of a safe culture lies in instilling a ‘collective mindfulness’ of the many entities that can penetrate, disable or bypass the system’s safeguards. Weick calls reliability and safety dynamic non-events. This means that people assume nothing bad will happen today because they acted the same as yesterday, and yesterday nothing bad happened.

Gradations of Cultural Change

At any time an organization can be in the stages mentioned below. This is a continuum that presents the path along change. Only the last one mentioned is the one that involves a successful transition in change.

• State 1: Don’t accept the need of change: The managers are happy with the status quo, they do not belief they have a problem and are satisfied with the way they are achieving their targets.
• State 2: Accept the need for change, but don’t know where to go. There is a concern over a series of bad events. They recognize that the existing safety measures are not accurate, but the cultural deficiencies are not understood.
• State 3: Know where to go, but don’t know how to get there. Acknowledge that the existing safety measures are less than adequate, and accept the cultural deficiencies but unsure how to make the necessary improvements.
• State 4: Know how to get there, but doubt whether the organization can afford it. Current projects are overrunning the budget, so they are willing but not able.
• State 5: Make changes, but do them only cosmetically. Making changes, but with short cuts.
• State 6: Make changes, but no good comes of them. The model of the change in the origination is not realistic and does not align with the real world.
• State 7: Model aligns today but not tomorrow. The change only brings limited benefits due to unforeseen changes.
• State 8: Successful transition. The change in the organization keeps up with the dynamic world and brings benefits.

Vulnerable System Syndrome

It is usually bad luck when the holes in the defensive system align to create an error. However some organizations are especially prone to having accidents. These organizations are suffering from the Vulnerable System Syndrome (VSS) and have three interacting and self-perpetuating elements: blaming front-line operators, denying the existence of systemic error provoking features and the blinkered pursuit of the wrong kind of excellence. VSS is present in some degree in all organizations; it is a matter on how an organization is taking effective remedial action. Blame and denial are the more dangerous elements of the VSS and differ on organizational and personal level.

At the personal level of the dynamics of blame and denial, there are several factors that influence the level:

• Fundamental attribution error: When someone else is performing less, we blame it on the person. When we perform less we attribute it to situational factors.
• Illusion of free will: People (especially in the west) value the belief that we are in control of our own destinies.
• ‘Just world’ hypothesis: This is the belief that bad things happen to bad people and vice-versa. This also means that the person is judged by the severity of the outcome.
• Hindsight bias: The tendency to see past events as more foreseeable on the spot than they actually where at that time.
• Outcome bias: The tendency to evaluate prior decisions according to the outcome. Another belief is that bad outcomes can only come from bad decisions, but history tells us that belief is not true.

At the organizational level of the dynamic of blame and denial, there also some factor that influence the level:

• Shooting or discounting the messenger: Ron Westrum distinguished three kinds of safety cultures: pathological (organizations that shoot the messenger and ignore or deny the information), bureaucratic (the large majority of the organizations that listen to the messenger but don’t really know what it means) and generative (these organizations welcome the messenger and praise him for it and treat the message very seriously).
• Principles of least effort: It is fairly easy to find a mistake that an individual made, which in some organizational causes the investigation into the error to stop early.
• Principles of administrative convenience: By restricting the area of investigations to the persons that are directly in contact with the system, it is easier to blame someone.
• Entrapment: Weck called the culture of entrapment “through repeated cycles of justification, people enact a sensible world that matches their belief, a world that is not clearly in need of change”.
• Organizational Silence: A climate in an organization where people don’t speak up when they feel there is an issue.
• Workarounds: When looking at the people working front-line, we see that for the most part they are solving local problems (daily tweaking, messaging, adjusting) to get the job done. When there is a problem they tend to work around it instead of fixing the underlying organizational problems.
• The normalization of deviance: Certain defects become so commonplace and so apparently inconsequential that their risk significance is gradually downgraded, so they are more seen as routine wear and tear.

Cultural Strata

Patrick Hudson expended the typology of the organizational safety cultures (Ron Westrum). The identified stages that each have to be passed through to move on to the next level. The first stage is pathological where blame and denial are the cheaper and faster way to solve problems. The second stage is reactive where safety is only given attention after an event because there is concern about adverse publicity. The third stage is bureaucratic/calculative, where there are systems to manage safety but often only because there was external pressure and also strictly by the book. The fourth stage is the proactive stage. This stage entails the awareness of the error traps in the system and they then seek to eliminate them before they happen. The final stage is generative, in this stage risks are anticipated, respected and responded to. It is an adaptive, flexible and learning culture that strives for resilience.

Should healthcare professionals tell their patients that they made an error – even when it has minor consequences? Or would this lead to more persons involved in a lawsuit? These questions are central to this question. This chapter will focus on the developments regarding this subject in the US.

Reporting Systems

Next to the patient safety movement, the IOM report also set in motion a series of events that led directly to the disclosure issue (to tell or not to tell). The publication led to an increase in malpractice premiums (health insurance) and lead to more state mandatory reporting systems. These systems serve three purposes:

• They protect patients with the knowledge that any serious errors must be reported and will be investigated.
• They give healthcare organizations an inventive to have a systematic approach to patient safety. The system approach brings out mistakes into the open in order to fix the organizational flaws and avoid future lapses. The tort system blames individuals for their errors and uses punishments to avoid future lapses.
• Mandatory reporting systems require all healthcare facilities to make some level of investment in patient safety.

Reporting Obstacles

As mentioned before, errors in healthcare are not accepted nor expected. They are stigmatized, marginalized and equated with medical incompetence. It is only logic that the new reporting systems made health professionals hesitant, because this could lead to more malpractice suits. However, research shows that there is no causal connection between mandatory reporting and more malpractice suits.

Whereas disclosing (reporting mistakes can happen) has been around a little longer, the practice of offering an apology is new. The Veterans Affairs Medical Centre (VAMC) gets the credit for getting the ball rolling regarding making apologies. In 1987 they adopted the ‘disclose-apologize-compensate’ approach, which is in sharp contrast with the ‘deny and defend’ approach. 12 years later it was confirmed that this new approach was the way to go in the medical profession. Research concluded that compensating patients and meeting their interest was relatively inexpensive in comparison with a malpractice lawsuit. Nancy Lamo suggests that the IOM and the VAMC reports brought about a cultural change in terms of transparency, disclosure and apology in the medical profession.

In 2005 Barack Obama and Hilary Clinton proposed a bill to establish the National Medical Error Disclosure and Compensation Program that built further on the Patient Safety and Quality Improvement Act that in 2006 was still pending in the senate.

How an apology is framed and delivered is important. Albert Wu (Johns Hopkins) pointed out that is not so much what is said but what the recipient hears that matters. Lee Taft argues that for an apology to be authentic is must contain:

• An acknowledgment that a rule or protocol has been violated
• An expression of genuine remorse and regret for any harm caused
• An explicit offer of restitution
• A promise of reform

The University of Michigan Health System (UMHS) Program: A Before and After Study

The study compares liability claims before and after the implementation of the UMHS disclose-with-offer program (disclosing and compensating). The results show fewer lawsuits, faster resolution and lower costs. Richard Boothman said that honesty is the basis of the three principles that are embodies in the UMHS study. First, when inappropriate medical care costs any harm, the provider of the care owes the patient a quick compensation. Second, when there was no patient injury the caregivers should get a thoughtful and vigorous defence. Third, the underlying aspect is the need to learn from patients’ experiences to improve the overall quality of care.

Criticism on this study

Of course, not everyone agrees. David Studdert, Dr. Atul Gawanda and Dr. T. Brennan are three very influential people in the medical world that co-wrote a paper that has a contrary view on the IOM report. They wrote that the chance that disclosure would decrease either the frequency or cost of malpractice litigation was remote. They even found it to be likely that the costs and litigation volume was to rise. The conclusions were based on the following observations: a vast majority of patients even suffering form a result of a medical error never sues, one of the reasons for this is that most people don’t know that they are a victim of a medical error, so the authors conclude that if these people are made aware of the fact that they were victims the number of claims will be rising.