Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

How did quality and safety become 4-letter words?

R. Christopher Call, MD, Michael O'Connor, MD, and Keith Ruskin, MD
Policy
July 14, 2022
Share
Tweet
Share

A guest column by the American Society of Anesthesiologists, exclusive to KevinMD.

A decade of working in quality and patient safety has taught me a painful lesson: Don’t say “quality” or “patient safety” to frontline health care workers. Too often, they become immediately defensive or evasive. How did q#^l&ty and s^f*ty become four-letter words? A key lies in understanding the safety model that medicine has embraced.

In 1978, British statistician George Box wrote, “All models are wrong, but some are useful.” When tackling complex problems, we rely on mental models to simplify complexity. These models utilize assumptions and simplifications that normally do not significantly degrade their performance. Occasionally, a model’s shortcomings become the very issue needing to be solved.

My college chemistry professor taught me to consider model inaccuracies. I had previously studied the Bohr atomic model, with each nucleus surrounded by electron orbitals. One simply had to find the proper elemental balance that filled the orbits to solve atomic equations. How hard could chemistry be? My naivety was exposed when my chemistry professor wrote a simple chemical equation on the board. Despite my best efforts, I could not balance the equation. The professor explained that the Bohr model would never reach the solution. It was an inadequate model. He then introduced the quantum electron cloud model.

The health care industry is struggling with its own version of the Bohr model – the Bad Apple Theory. As described by Sidney Dekker in The Field Guide to Understanding’ Human Error,’ the Bad Apple Theory assumes 1) Complex systems are basically safe and 2) These systems need to be protected from unreliable people. According to the Bad Apple Theory, a system’s main failure point is human error. Proponents argue that the health care system is effectively defined by policy, and patient safety events could be avoided if people stopped going off-script.

Under the Bad Apple Theory, system failures are explained by identifying human deviation. Underlying motives and circumstances may be cursorily explored, but the final cause is the individual’s failure to follow policy, protocol, or guidelines. This can occur even in the absence of plausible causation. When focusing on human deviation from expected behavior, solutions tend to lean towards worker education, training, certification, two-person verifications, or more rules and policies. Sound familiar? A 2018 study identified training, education, and policy development or revision as the most frequent root cause analyses interventions. Not surprisingly, all these interventions are considered “weaker actions” by the National Patient Safety Foundation (NPSF) RCA2 classification.

Numerous other indications suggest that a health care system is built on the Bad Apple Theory. Is the most common root cause of safety investigations “human error?” Has the name of the safety reporting system been adopted as a verb to denote “reporting a troublesome colleague?” Do frontline staff become nervous and defensive during safety investigations? In a culture where human deviation is the primary culprit, human correction becomes the primary intervention.

Safety experts have developed a more advanced safety model. In 1947, Army psychologists Paul Fitts and Richard Jones reviewed hundreds of aviation mishaps attributed to “human error.” Their report found that most “pilot errors” should have been attributed to deeper, systemic issues. For example, the flaps and landing gear in the “Flying Fortress” B-17 bomber used identical-style switches located next to one another. Pilots would accidentally retract their gear instead of the flaps during the crucial landing sequence. For years, this was attributed to “pilot error,” yet these mishaps all but disappeared once the cockpit design was modified.

Fitts’ report captures what would later emerge as the Human Factors Theory: “It should be possible to eliminate a large proportion of so-called ‘pilot-error’ accidents by designing equipment in accordance with human requirements.” Human Factors Theory seeks to identify and fix the underlying dynamics that lead to “human errors.” Sidney Dekker explained, “I no longer approach investigations as a search to find where people went wrong. Instead, I seek to understand why their assessments and actions made sense to them at the time.”

Under the Humans Factor Theory, failures are not satisfactorily explained by demonstrating human deviation from expected behavior. Instead, the circumstances and underlying pressures are meticulously explored, and systemic deficiencies are identified. Interventions lean towards design improvements, engineering controls, or process simplification and standardization. Staff and workload balance may be adjusted, or software enhancements may be pursued. These interventions are considered “intermediate” and “stronger actions” in the NPSF RCA2 classification.

In contrast to the Bad Apple Theory, the Human Factors Theory assumes 1) Complex systems are not fundamentally safe and 2) People create safety while negotiating multiple system goals. In other words, complex systems are filled with vulnerabilities, competing demands, and latent failure points. They constantly evolve. Despite attempts to codify operations, vulnerabilities will inevitably align, and a catastrophic failure becomes imminent. Under these circumstances, people’s ability to perceive the situation and adapt is the primary source of safety. The ability to deviate from expected behavior has recently been identified as a major source of safety in complex systems – a paradigm referred to as “Safety-II.”

In a culture where systemic vulnerabilities are the primary culprit, system corrections become the primary intervention, rather than human correction. People act as a final safety net when the system inevitably threatens failure. Imagine working in a health care system that views its workers as the solution, not the problem. Perhaps we could start using “quality” and “patient safety” again.

Disclaimer: The views expressed in this article are those of the author and do not necessarily reflect the official policy of the Department of Defense or the U.S. Government. The appearance of non-U.S. Government web links does not constitute endorsement by the Department of Defense (DoD) of the websites nor the information, products, or services contained therein. Such websites are provided consistent with the purpose of this publication.

ADVERTISEMENT

R. Christopher Call, Michael O’Connor, and Keith Ruskin are anesthesiologists.

Image credit: Shutterstock.com

Prev

The building blocks of a cancer risk management strategy

July 14, 2022 Kevin 0
…
Next

These are the women who are being told they are not a priority

July 14, 2022 Kevin 4
…

Tagged as: Hospital-Based Medicine, Public Health & Policy

Post navigation

< Previous Post
The building blocks of a cancer risk management strategy
Next Post >
These are the women who are being told they are not a priority

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

Related Posts

  • Quality measures have gotten ahead of the science of quality measurement

    Peter Ubel, MD
  • Should doctors take more responsibility for quality metrics?

    Sarah Gebauer, MD
  • Redefining quality through a patient-centered approach

    Anne Zink, MD
  • When quality measures interfere with good care

    Michael McCutchen, MD, MBA
  • An important health care safety net is at risk

    Mark Pappadakis, DO
  • Race to the bottom: The myth of low-quality care in America

    Eric W. Toth, DO

More in Policy

  • U.S. health care leadership must prepare for policy-driven change

    Lee Scheinbart, MD
  • How locum tenens work helps physicians and APPs reclaim control

    Brian Sutter
  • Why Medicaid cuts should alarm every doctor

    Ilan Shapiro, MD
  • Why physician voices matter in the fight against anti-LGBTQ+ laws

    BJ Ferguson
  • The silent toll of ICE raids on U.S. patient care

    Carlin Lockwood
  • What Adam Smith would say about America’s for-profit health care

    M. Bennet Broner, PhD
  • Most Popular

  • Past Week

    • When did we start treating our lives like trauma?

      Maureen Gibbons, MD | Physician
    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
    • How to speak the language of leadership to improve doctor wellness [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why some doctors age gracefully—and others grow bitter

      Patrick Hudson, MD | Physician
    • How to survive a broken health care system without losing yourself [PODCAST]

      The Podcast by KevinMD | Podcast
    • How the shingles vaccine could help prevent dementia

      Marc Arginteanu, MD | Conditions
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • Addressing the physician shortage: How AI can help, not replace

      Amelia Mercado | Tech
    • Why medical students are trading empathy for publications

      Vijay Rajput, MD | Education
    • Physician patriots: the forgotten founders who lit the torch of liberty

      Muhamad Aly Rifai, MD | Physician
  • Recent Posts

    • How to speak the language of leadership to improve doctor wellness [PODCAST]

      The Podcast by KevinMD | Podcast
    • Ethical dilemmas in using unclaimed bodies for medical research

      M. Bennet Broner, PhD | Physician
    • The Nova Oath: a physician’s pledge to courageous and ethical care

      Kenneth Ro, MD | Physician
    • AI is not a threat to radiologists. It’s a distraction from what truly matters in medicine.

      Fardad Behzadi, MD | Tech
    • How deep transcranial magnetic stimulation is transforming mental health care

      Muhamad Aly Rifai, MD | Conditions
    • True stories of doctors reclaiming their humanity in a system that challenges it

      Alae Kawam, DO & Kim Downey, PT & Nicole Solomos, DO | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 3 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • When did we start treating our lives like trauma?

      Maureen Gibbons, MD | Physician
    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
    • How to speak the language of leadership to improve doctor wellness [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why some doctors age gracefully—and others grow bitter

      Patrick Hudson, MD | Physician
    • How to survive a broken health care system without losing yourself [PODCAST]

      The Podcast by KevinMD | Podcast
    • How the shingles vaccine could help prevent dementia

      Marc Arginteanu, MD | Conditions
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • Addressing the physician shortage: How AI can help, not replace

      Amelia Mercado | Tech
    • Why medical students are trading empathy for publications

      Vijay Rajput, MD | Education
    • Physician patriots: the forgotten founders who lit the torch of liberty

      Muhamad Aly Rifai, MD | Physician
  • Recent Posts

    • How to speak the language of leadership to improve doctor wellness [PODCAST]

      The Podcast by KevinMD | Podcast
    • Ethical dilemmas in using unclaimed bodies for medical research

      M. Bennet Broner, PhD | Physician
    • The Nova Oath: a physician’s pledge to courageous and ethical care

      Kenneth Ro, MD | Physician
    • AI is not a threat to radiologists. It’s a distraction from what truly matters in medicine.

      Fardad Behzadi, MD | Tech
    • How deep transcranial magnetic stimulation is transforming mental health care

      Muhamad Aly Rifai, MD | Conditions
    • True stories of doctors reclaiming their humanity in a system that challenges it

      Alae Kawam, DO & Kim Downey, PT & Nicole Solomos, DO | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

How did quality and safety become 4-letter words?
3 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...