Patient Safety: A Human Factors Approach

At last, a book about risk management that does not keep comparing surgeons with airplane pilots. Although there are things to learn from this comparison, it just seems absurd to suggest that a closed cockpit resembles, in any way, the challenging environment offered by our hospitals and operating theatres (perhaps it might if the stewards sneaked into the cockpit and changed the settings, the fuel gauges did not work, and the airline kept ringing pilots for advice when they were between shifts). Decker explains the differences in terms of ‘complex’ and ‘complicated’ systems. He comments that ‘Complicated systems are pretty stable, closed to the environment, and ultimately knowable and controllable and should follow one best method. Complex systems are never fully knowable – they are open to the environment and always changing. Order emerges from the multitude of relationships and interactions between component parts.’ It is possible to learn about complicated systems by breaking them down into their component parts, whereas this does not work in complex systems. My only reservation with this concept is that the second edition of the Collins Australian Thesaurus gives the reverse interpretation of ‘complex’ and ‘complicated’. It states that ‘Although complex and complicated are close in meaning, care should be taken when using one as a synonym of the other. Complex should be used to say that something consists of several parts rather than that it is difficult to understand, analyze or deal with, which is what complicated inherently means.’ Nevertheless, this insight helps explain many of the frustrations that we feel about hospitals. The message is clear, patient safety can only be improved by reducing the complexity associated with our current health-care systems – things work best when defined tasks are undertaken by harmonious multidisciplinary teams. Perhaps, that is why so many of us regard the operating theatre as a haven. The book is divided into eight chapters about medical competence and patient safety, human error, cognitive factors, new technology and automation, safety culture and organizational risk, practical tools for creating safety, accountability and learning from failure, and new frontiers. Decker continually pushes the need to unravel complexity and throw away the perverse command and control mentality that still pervades our health-care systems. He comments that managerial control ‘is not at all the same as being in control of the consequences’ because the real world is too variable and unpredictable – our actions are embedded in ‘histories, rituals, interactions, beliefs, and myths.’ And, as a consequence, ‘Numbers that may seem managerially appealing are really sterile, inert.’ Amen to that. Decker has written a book that is essential reading for anybody concerned about patient safety. It represents a genuine turning point in the way that we perceive efforts to make hospitals a safer place. It should be carefully read by everyone who professes to have an interest in patient safety.