This study closely examines the interpretation and translation challenges faced by Pennsylvania patients and providers, and how they affect patient safety. It also provides strategies and recommendations for facilities to supplement available language services, such as hiring staff bilingual in English and the common languages of the service area and explaining common procedures with visual aids and pre-translated materials.

141 people experienced at least a single perceptual error. Even the most clinically significant event (disconnection of the patient's oxygen supply) was missed by three in four viewers. Although expertise was associated with increased likelihood of detecting an occurrence, even highly significant events were missed by up to two thirds of the most experienced observers.

This study demonstrates that perceptual errors occur during healthcare-relevant scenarios at significant levels. Events such as an oxygen malfunction would meaningfully affect patient outcome and, although expertise conferred some advantages, events were still missed more often than not. Data acquisition is fundamental to good-quality situational awareness. These results suggest perceptual error may be a contributor to adverse events in practice.

Using a convenience sampling method, 65 trauma team members (e.g., surgeons, physicians, nurses) from six Level I trauma centres in the United States were recruited to participate in 20 focus groups. Focus groups were semi-structured and 1 hr long.

Staff covered issues related to communications and disruption from noise sources (e.g., equipment, conversations). Having control over lighting allows staff to change light intensity and facilitate their work during the resuscitation. A well-maintained temperature can provide patient comfort or reduce risk of hypothermia, given that patients can lose body heat rapidly due to loss of blood.

The study found that excessive sensory stimuli can result in disrupted communication, fatigue, and stress, making staff susceptible to errors. Staffs’ control over environmental conditions may lead to a more efficient, comfortable, and safer environment. Technology should be reliable and flexible to facilitate this.

In 2009, I joined a team at University College London Hospitals (UCLH) that had adapted the AAR concept from the military for use in the NHS. AAR provides a deceptively simple vehicle to structure healthy blame-free team interactions and the aim was to improve patient safety, clinical practice and team behaviours.[2] The AAR approach has since become business as usual at UCLH where it is now widely understood and frequently used.

What my colleagues at UCLH recognised so well is that AAR is so much more than the four questions you get when you type After Action Review into a search engine[3] and, thus, designed the introduction of the approach with this in mind. A paper in the Harvard Business Review[4] describes why AAR has so often failed in the corporate environment and this gives useful insights, but I have witnessed three particular challenges in the healthcare setting.  

1. Fear

The organisational and psychological barriers to being able to talk honestly about errors in multi-professional teams are accentuated by the hierarchical nature of the clinical context. Put simply, this means despite everyone’s best intention to learn from a near-miss or an unexpected event, there will be fear about being fully open in front of those more senior or junior and those from other disciplines. If we are being really honest with ourselves, we know this to be true. Fear of what others think about what we have done, and whether it will affect our standing in some way, is a universal human trait which is increased when the boss is in the room. This fear is in direct tension with the AAR concept of openness and cross-disciplinary learning and will act as a barrier to calling AARs unless leaders act as role models in AARs and set the scene by being honest and open themselves. 

 2. Blame

The emotive nature of clinical care heightens the response when things go wrong meaning the tendency to find something or someone to blame is increased. Not only do we have institutional demands pressing hard for straightforward answers, meaning we look for something obvious to blame, we also have our own human reaction to distance our self from responsibility. This traditional reaction again lies in direct tension with the very idea of AAR, where the process is not to blame but to learn. The research is clear, that in this most complex of operating environments there is rarely a single point of failure or a single individual who is to blame, instead there are multiple causes and effects, which, when better understood, provide a firm place from which to make effective changes. 

3. Responsibility

The concept of clinical professionalism is centred around the individual’s responsibility to deliver safe effective care and it is rooted in the very foundations of how the NHS was created. Clinicians are raised in the belief that they should know the answers to problems and the whole structure of career progression is based around acquiring more knowledge, research papers and letters after your name. AAR is a process of learning as a group and taking responsibility together to find out how to improve, so it is not surprising that it sits in tension with the historical emphasis on the individual healthcare professional and the value of their existing knowledge. AARs allow for the creation of new knowledge through a collaborative process. 

The joint guidance from the General Medical Council (GMC) and Nursing & Midwifery Council (NMC) on the professional duty of candour states: “Clinical leaders should actively foster a culture of learning and improvement.”[5] AAR is one of the best mechanisms to both foster and drive a culture of learning and improvement, but the simplicity of the AAR process itself should not blind you to the need to be very considered in how you mitigate and manage the barriers in a clinical setting. 

If you would like to discuss AARs further, I'd love to hear from you. Contact me at: judy.walker@its-leadership.co.uk

References

1. Tannenbaum SI, Cerasoli CP. Do team and individual debriefs enhance performance? A meta-analysis. Hum Factors 2013;55(1):231-45.
2. Walker J, Andrews S, Grewcock D, Halligan A. Life in the slow lane: making hospitals safer, slowly but surely. J R Soc Med 2012;105(7):283-7. doi: 10.1258/jrsm.2012.120093.
3. NHS Improvement. Online library of Quality, Service Improvement and Redesign tools: After Action Review.
4. Darling M, Parry C, Moore J. Learning in the Thick of It. Harvard Business Review: July-August 2005 issue.
5. Nursing and Midwifery Council. Openness and honesty when things go wrong: the professional duty of candour. June 2015.

Read Judy's previous blog: How can After Action Reviews improve patient safety?

People grow more accustomed to the deviant behaviour the more it occurs . To people outside of the organisation, the activities seem deviant; however, people within the organisation do not recognise the deviance because it is seen as a normal occurrence. In hindsight, people within the organisation realise that their seemingly normal behaviour was deviant.

Diane Vaughan uses healthcare to illustrate  why deviance is normalised in companies. She gives four major reasons why it happens:

• "The rules are stupid and inefficient." System operators will often invent shortcuts or workarounds when the rule, regulation, or standard seems irrational or inefficient.
• Knowledge is imperfect and uneven. System operators might not know that a particular rule or standard exists; or, they might have been taught a system deviation without realising it.
• "I’m breaking the rule for the good of my patient!" This justification for rule deviation is where the rule or standard is perceived as counterproductive.
• Workers are afraid to speak up. The likelihood that rule violations will become normalised  increases if those who witness them refuse to intervene. Yet, studies show that people feel it is difficult or impossible to speak up. 

Solutions

Vaughan offers the following suggestions for helping to prevent deviant behaviours from becoming normalised:

• Education is the best solution for the normalisation of deviance. Diane Vaughn states, "the ignorance of what is going on is organisational and prevents any attempt to stop the unfolding harm." Being clear about standards and rewarding whistleblowers is part of the education that should take place. A company must be transparent about their standards and consequences of not meeting them.
• Also, creating a culture that is less individualistic and more team-based is helpful to stop the normalisation of deviance. Each person should be looking out for the company and team as a whole. If it were more team-based, each person would feel like they were letting their colleagues down if they were to break the rules.
• A top-down approach is very important. If the employees see executives breaking rules, they will feel it is normal in the company's culture.
• Normalisation of deviance is easier to prevent than to correct. Companies must make sure they take the correct steps to prevent it.