The error of your ways

Professor Brian Toft

Abstract

This article is based upon a paper published in 'Healthcare Services Management Research' 18: 211-216, 2005 by Professor Mascie-Taylor, Medical Director, The Leeds Teaching Hospitals NHS Trust and the author.  It is argued that it is possible for errors to be missed and accidents to occur because the job and the operational work environment can drive those undertaking double-check safety protocols to become victims of a previously undiscovered socio-psychological mechanism labelled 'involuntary automaticity'.   

Introduction

Having completed their routine verbal double-checking safety pre-landing checklist, the aircraft crew of a Boeing 737 was preparing to land in Wyoming in March 1983.  The call from the captain to the co-pilot to lower the landing wheels was followed by the announcement from the co-pilot that the landing wheels were now down.  Why was it, then, that the aircraft landed wheels-up - a potentially highly dangerous and costly scenario for the airline, the aircraft, the crew and its passengers?

In high-consequence activities like aviation and medicine, verbal double-checking safety procedures are used to reduce the chances of an accident occurring - the expectation being that if one person misses an error the other will detect it.  But the fact that a verbal double-checking safety procedure has been carried out does not always prevent an accident.

Similarly, in medicine, the use of a verbal double-checking safety procedure does not always ensure patient safety.  One recent study shows that errors in the administration of drugs to patients was greater than two per 1000 doses even though two members of staff had been involved in the checks.

Likewise, an analysis of patients who had been transfused blood with the wrong component revealed that 77 per cent of these adverse events had occurred when at least two members of staff had been involved in carrying out the identification checks.

It follows, then, that a verbal double-checking safety procedure does not necessarily ensure that if an error is present in the process that is being checked, that the error will be identified and an adverse incident prevented from taking place.  It is also worth noting that when a double-checking process does fail and an accident occurs, it is often the individuals who undertook the check that are blamed for the adverse incident occurring.

Conscious automaticity

The term 'automaticity' describes the '…property of a process that takes place largely independent of conscious control and attention' - in the same way as the practiced driver can efficiently coordinate actions without a great deal of mindful effort.  It is not least in this way that automaticity is usually discussed in terms of the benefits that it brings as opposed to any potential cost it may have.

Involuntary automaticity

There may be a price to pay, however, for the ability to improve performance through automaticity: the repeated use of identical checking procedures can inadvertently lead to the process becoming unconsciously ritualised and checklist items begin to take the form of a litany where eventually the actual behaviour required by the check may not be carried out.  This is because although a check requires close attention, once involuntarily captured by the ritualised automaticity, only a superficial amount of attention will be paid to the information being verified.  Thus if an error is present in the data being checked it is likely to be missed without the individuals undertaking the check realizing it.
Other evidence suggests that such a situation is more likely to develop where the members of a team are well acquainted with each other, trust each others’ professional judgement, and are subject to high workloads, interruptions or distractions.

Similarly, in his article 'Treatment Errors in Radiation Therapy' Radiologist, John French observed that in some situations, the system failed completely.  According to French, "major errors went undetected despite independent verification checks at several points… [The evidence suggests this may have occurred because] radiation therapists mechanically followed procedures, whereby verification [of the x-ray machine settings was] completed but not performed effectively".

With regard to the dangers of involuntary automaticity in an aircraft cockpit Olcott reports that one of the conclusions made by investigators following one fatal air crash was that, "The air carrier crew at LGA (New York La Guardia Airport) went through the motions of reading a checklist but responded without being effective".  This strongly resonates with the circumstances reported by French.

In their book Absent-minded? The Psychology of Mental Lapses (1982), James Reason and Klara Mycielska suggest that human errors like these are "the price we pay for being able to carry out so many complex activities with only a small investment of conscious attention.  They are the inevitable penalty of the necessary process of automatization".

Ambiguous accountability

Yet another factor that can aid the inadvertent activation of involuntary automaticity during the use of a verbal double-checking procedure is that two individuals may come to rely upon each other to be rigorous, with the result that neither gives the task their full attention.

In a review in 1994, carried out by haematologists Linden and Kaplan, and reported in Transfusion Medicine Reviews, they observed: "Unless carefully configured to prevent it, in a system in which two people are responsible for the same task, neither person is truly responsible. Paradoxically, such safety procedures may provide less, rather than more assurance".

On top of this, there also appears to be evidence that a person's job and the stresses in their operational work environment may play a substantial role in providing the conditions for involuntary automaticity to occur.

Remedial actions

It has been reported in the aviation industry that one way in which verbal double-checking errors have been missed is through a pilot calling out several items at once with the result that the other pilot responded in the same way.  Such behaviour clearly undermines the whole concept of the challenge-response method.  Thus, one way in which such errors can be minimised is through the person reading out the checklist to call out each item separately and wait for the other person to respond to that request before moving on to the next item.

A second way is through the use of an independent check, where each individual undertaking the verbal double-check carries out the whole process, i.e. the first person reads out the items on the checklist for the other person to check and then vice-versa.

Yet another way to improve the safety of verbal checking protocols might be to use electronic barcode technology so as to reduce reliance on human judgement during such checks.

While reducing the stresses associated with heavy workloads, time pressures, interruptions and distractions could diminish the chances of involuntary automaticity capturing those undertaking verbal safety protocols.    

Conclusion

Evidence has been found that suggests mishaps can occur in a range of different organisational setting because the verbal double-checking protocols used do not provide the level of safety anticipated.  The problem arises because involuntary automaticity causes those undertaking the checks to miss an error that is present.  As a consequence those undertaking the check form a false hypothesis regarding the safety of the action they are about to take and this leads to an unwanted incident occurring.

Therefore, if the management of all organisations using verbal double-checking protocols were to implement remedial actions to address the organisational factors that can lead to the production of involuntary automaticity then the risk of accidents occurring could be reduced internationally.

Acknowledgements

This article is based upon work previously published in the Continuity Insurance & Risk magazine in July 2005, www.cirmagazine.com 

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