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Anyone who knows me will know how important patient ID is. It’s really easy to make these kinds of mistakes because of the way our brains work.
However if we understand these issues there are things we can do to prevent errors!
A thread...
1/16 https://twitter.com/dglaucomflecken/status/1347419357236789248
However if we understand these issues there are things we can do to prevent errors!
A thread...
1/16 https://twitter.com/dglaucomflecken/status/1347419357236789248
You might think that you know what goes on around you but your brain filters out information/stimuli it receives which it feels is irrelevant or which conflicts with its expectations.
This is called “sensory gating”. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4127047/
2/16
This is called “sensory gating”. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4127047/
2/16
You might think that this relates to the finer details but actually your brain may decide to filter out some pretty big things.
Check out these experiments by Simons & Levin
3/16
Check out these experiments by Simons & Levin
3/16
Another point to consider is how our conscious and unconscious mind works. Both are operating at the same time with the brain deciding which elements need to be dealt with by the conscious and unconscious sides.
https://www.scientificamerican.com/article/the-brains-autopilot-mechanism-steers-consciousness/
4/16
https://www.scientificamerican.com/article/the-brains-autopilot-mechanism-steers-consciousness/
4/16
We know we can miss things through inattentional blindness. So what is driving that when we *think* we’re checking properly?
Well that can be down to experience... You have checked a patient’s identity hundreds or thousands of times. It’s always been right.
5/16
Well that can be down to experience... You have checked a patient’s identity hundreds or thousands of times. It’s always been right.
5/16
This is an example of a “Heuristic”, a mental shortcut that means we can process information, make decisions and take actions more quickly based on the predictions our brains make about how things are going to be.
(Kahneman D., Thinking Fast and Slow, 2011).
6/16
(Kahneman D., Thinking Fast and Slow, 2011).
6/16
Heuristics are important to every day life as they can allow us to act in an automated fashion without having to analyse everything. However they also create “cognitive bias”. Where our brains don’t expect see an error it has been “primed” to expect that things will match.
7/16
7/16
Add this to sensory gating including the brain’s ability to filter out conflicting information and it becomes unsurprising that ID errors occur. Then consider the environment and tasks that clinical staff are juggling increases the number of sensory inputs being filtered.
8/16
8/16
We might go to a patient with a request form or set of notes and ask the patient to tell us their details while we look at the paperwork. The brain processes & filters the audio and visual inputs and we perceive them as matching when perhaps they don’t.
9/16
9/16
During our doctors’ induction sessions we ask the new medics to do a sampling assessment with us acting as the patient. Like Simons and Levin, we find around 50% won’t notice if we state the wrong DOB. They are often quite disbelieving when the error is highlighted.
10/16
10/16
Now we know how our own minds can be working against us we can think about what to do about it.
Firstly reduce unhelpful sensory inputs
1) Look at how interruptions and distractions can be avoided.
2) Don’t look at the patient’s ID on the paperwork while they state it.
11/16
Firstly reduce unhelpful sensory inputs
1) Look at how interruptions and distractions can be avoided.
2) Don’t look at the patient’s ID on the paperwork while they state it.
11/16
Secondly create helpful sensory inputs.
1) complete forms with the patient details before attending the patient
2) After the patient has stated their details repeat them back and ask them to spell their name
3) THEN look at the patient wristband and repeat the spelling
12/16
1) complete forms with the patient details before attending the patient
2) After the patient has stated their details repeat them back and ask them to spell their name
3) THEN look at the patient wristband and repeat the spelling
12/16
4) Hold the paperwork created in 1) right next to the wristband so you can see any differences and make sure you have actually come to the right person.
Thirdly address the bias - expect there to be an error, a tiny one, be surprised when there isn’t!
13/16
Thirdly address the bias - expect there to be an error, a tiny one, be surprised when there isn’t!
13/16
We often see clinicians asking another person to check as a method of improving safety but counterintuitively this actually reduces safety as both brains expect the other will detect the error and don’t spot inconsistencies.
Check once well rather than twice badly!
14/16
Check once well rather than twice badly!
14/16
Perception errors affect all aspects of patient care not just patient ID. Medication, transfusion, surgery, tests, diagnoses and treatment can all be incorrect. Even in the mortuary errors can occur which causes distress to families.
Yet we can prevent them!
15/16
Yet we can prevent them!
15/16
Mostly things do go right and when they don’t this doesn’t mean we are bad people. When it happens (it will) being open and honest with yourself and others helps people like me understand how the error occurred and how we can help prevent recurrence.
Keep safe
16/16
Keep safe
16/16
Bonus tweet!
Look at this cool example of sensory gating showing how your visual stimuli affects your brain’s perception of the auditory stimuli. https://twitter.com/theprisonlawyer/status/1347626960529326080
Look at this cool example of sensory gating showing how your visual stimuli affects your brain’s perception of the auditory stimuli. https://twitter.com/theprisonlawyer/status/1347626960529326080
