Deviations from protocol in a complex Trauma environment: Errors or innovations?

Abstract

Protocol standardizations are important for consistent and safe practices. However, complex clinical environments are highly dynamic in nature and often require clinicians, confronted with non-standard situations, to adjust and deviate from standard protocol. Some of these deviations are errors which can result in harmful outcomes. On the other hand, some of the deviations can be innovations, which are dynamic adjustments to the protocols made by people to adapt the current operational conditions and achieve high accuracy and efficiency. However, there is very little known about the underlying cognitive processes that are related to errors and innovations. In this study we investigate the extent to which deviations are classified as errors or innovations, as a function of expertise in a trauma setting. Field observations were conducted in a Level 1 trauma unit. A total of 10 trauma cases were observed and collected data was analyzed using measures that included customized activity-error-innovation ontology, timestamps and expertise of the team members. The results show that expertise of the caregivers and criticality of a patient's condition in critical care environment influence the number and type of deviations from standard protocol. Experts' deviations were a combination of errors and innovations; whereas the novices' deviations were mostly errors. This research suggests that a novel approach must be taken into consideration for the design of protocols (including standards) and compliance measurements in complex clinical environments.

Nurses’ workarounds in acute healthcare settings: a scoping review

“…Definitions of violations offered in two of the seven studies specified that violations were not intended to harm [40,43]. In other studies, definitions offered for first order problem solving and deviations matched our definition of workarounds [24,58,59,73]. In this paper we use the term workaround to refer to behaviours that match the definition in this study (e.g.…”

“…Study settings comprised hospitals that provided general medical, specialised paediatric and psychiatric services [60], and a variety of wards including, but not limited to: intensive care [1,4,35,58,59,61-66], medical and surgical [1,4,35,45,46,58,59,62],[64,66-70], oncology [1,50,58,59,62,64,65], maternity [1,58,59,62,66,67,71], cardiac units [1,45,50,58,59], operating theatre units [38,52,62,72], emergency and trauma departments [35,57,58,62,73-75], outpatient clinics [76] and paediatrics [1,35,40,53,54,58-60,63-66,71]. These wards were identified in academic [48,49,58,64,71,75,77,78] and non-academic [58,61,72], community [1,58,59,61,62,72,79], tertiary [45,58,64] and teaching hospitals [1,40,46,52-54,59,79], in urban [1,45,53,...…”

“…The majority of studies offered exemplars of workarounds (n=46). However, some did not detail workaround practices [1,38,43,47,55,60,62-64,73],[83]. While in most studies examples of behaviour were clearly workarounds, there were some studies in which it was more difficult to determine and for these it was necessary to consult the offered causes of the behaviour to determine whether it could be defined as a workaround.…”

Role of cognition in generating and mitigating clinical errors

“…We found that trauma physicians (experts), when they deviated from standardised protocols, made significantly fewer errors when compared with first-year and second-year residents (comparative novices) 44. The deviations occurred under conditions of complexity, as well as in the presence of high levels of uncertainty about the patient's condition.…”

New tools for high reliability healthcare

“…Over the past decade, Patel and colleagues have carefully documented the reasons medical errors occur, with special appreciation for the role of complexity in clinical situations 2 3. Due to that complexity, and in recognition of the fallibility of human care, the issue quickly becomes how to mitigate errors before patients are adversely affected.…”