Black box thinking: why we make mistakes and learning from them

Mistakes, in general, are extremely common – you have probably already made a few today by the time you come to read this article.

They are usually harmless, sometimes irritating and occasionally serious – and they are an inherent part of being human.

So, what happens if you work in an environment where mistakes cost lives? What if a simple misjudgement, oversight or poor decision causes irreparable damage, and being human just isn’t good enough?

In the world of human health care, 1 in 10 visits to hospital involve an error in the chain of care, and an estimated 400,000 people a year die as a result of doctors’ or nurses’ mistakes (de Vries et al, 2008).

While no equivalent published studies of incident rates exist in the veterinary literature, anyone who has worked in practice for long knows it doesn’t always go to plan.

Just as in any other form of work, things get missed or forgotten, and even the best and brightest occasionally underperform.

The problem is if you’re a vet or vet nurse, that can mean unwanted outcomes for your patients, complaints from your clients and a deep sense of failure for the clinician involved.

Error is ubiquitous and inevitable in all walks of life, but in a safety‑critical industry where the consequences can be serious, learning from mistakes is advocated for professional development and patient safety.

Sounds easy, doesn’t it.

However, if you have ever had to present your worst case at a mortality and morbidity meeting or explain your actions to an angry client, you’ll know that reflecting on your own less‑than‑perfect performance is not a comfortable place to be.

Reporting system

So, how do we try to make painful conversations easier and ensure that revisiting uncomfortable circumstances is as positive an experience as possible for all involved?

We need a black box – a method of catching and recording things that go wrong so they can be investigated, analysed and, most importantly, understood.

Aviation has been on to this for decades. The first black boxes – flight recorders, to give them their correct name – have been installed in commercial airliners since the 1950s and the data they gather has subsequently been used in hundreds of thousands of accident investigations.

Through black box methodology, the industry has unpicked its mistakes and applied a human factors approach to error management, which has paid dividends in terms of technical design, team and individual training and organisational culture.

Human medicine has advocated a similar “learning from errors” approach since the Institute of Medicine’s (IOM) 2000 report, “To err is human”, and subsequent NHS paper, “An organisation with a memory” (Institute of Medicine, 2000; Donaldson, 2002).

These reports both called for a shift change in attitudes to mistakes – rather than blaming and shaming the clinician who “touched it last”, the IOM and NHS embraced aviation‑style practices of human factors and error management.

Medicine has since instituted its own version of a black box in the form of national reporting systems, such as the National Reporting and Learning System in the NHS. This central body captures, collates, analyses and shares learning from error reports, complemented by the newly established Healthcare Safety Investigations Branch.

Until recently, no comparable system existed for veterinary practice, but VetSafe – The Veterinary Defence Society’s online adverse event reporting system – has the potential to bring the profession in line with other industries: a black box for the veterinary profession.

Understanding why mistakes happen

VetSafe can help us to understand – really understand – why people make mistakes. This knowledge facilitates positive conversations through a constructive lens, the goal of which is to prevent or mitigate future errors, not point the finger at those involved.

Skilful facilitation of mortality and morbidity meetings, or significant event reviews can help to provide the psychological safety required to generate reporting cultures and supportive behaviours among colleagues.

Application of human factors, principles and techniques – such as root cause analysis – provide structure and direction to those conversations, maximising team learning and shifting the focus of investigation away from the individual concerned.

This systems focus is important in managing the potential effects of “second victim” syndrome. This term was introduced in human medicine in 2000 to explain the effects of error on medical staff and the fact clinicians can feel traumatised by their involvement in adverse events (Wu, 2000).

In the aftermath of errors, clinicians can feel they have failed their patient and start to second‑guess their clinical skills, knowledge base and career choice. It is also associated with negative emotions such as guilt, anger, frustration, psychological distress and fear.

Female doctors report significantly more distress than their male counterparts, and the condition is linked to burnout and depression (Muller and Ornstein, 2007; Scott et al, 2010).

Recent research has suggested similar issues may affect veterinary surgeons. A study by Kogan et al (2018) into the impact of errors and near misses on veterinarians in the US reported that many vets who were involved in mistakes were less satisfied with their job, less confident as a clinician, less happy overall and less self-confident, and had persistent feelings of guilt and trouble sleeping.

These findings mirror the symptoms of medical second victims, and have obvious relevance to personal well‑being and retention in veterinary practice.

Psychological safety

Critically, unlike a flight recorder or mandated health care reporting system, VetSafe relies on voluntary reporting of mistakes – and for that, clinicians require a degree of psychological safety.

The 10 most commonly cited barriers to disclosing errors in human medicine include professional repercussions, legal liability, blame, lack of confidentiality, negative patient/family reaction, humiliation, perfectionism, guilt, lack of anonymity and absence of supportive forum for disclosure (Kaldjian et al, 2006).

Evidence also suggests similar barriers exist in the veterinary sector. Hartnack et al (2013) investigated error reporting in equine anaesthesia, and suggested the discussion of mistakes in the veterinary context was stifled and imbued with a sense of fear; “no one talks about it”.

Subsequent research has mirrored these findings, with vets and nurses expressing fear, guilt and sadness when contemplating professional mistakes:

Researcher: “What’s your first thought if you really make a cock-up?”

Vet 1: “How am I going to tell the owner?”

Nurse 1: “And also gutted. Gutted for the animal and, s**t, am I going to get struck off?”

Nurse 2: “Just generally mortified.”

Vet 2: “You just feel really bad, don’t you. You know, if you had a patient death or something, you just feel awful.”

Nurse 1: “Horrible.”

Vet 1: “Awful.”

Nurse 2: “Absolutely.”

(Oxtoby, 2017)

To submit error reports, vets and nurses describe needing to “get over their own guilt” and refer to “fear and embarrassment” in the context of discussing mistakes with colleagues. Vets and nurses worry about the consequences of reporting errors – specifically the reactions of the RCVS, their colleagues, their clients and their boss (Oxtoby, 2019). They also have to grapple with their ingrained sense of ultimate professional responsibility and anecdotal perfectionist tendencies, which can result in clinicians focusing on their own shortcomings, actively berating themselves for their mistakes.

Black box thinking in practice

So, how can we facilitate black box thinking in the profession? How can we make sure we use our experience of the past to improve future performance for our patients, clients and ourselves? How can we ensure we learn from each other’s mistakes and support the clinicians involved in them?

Managing those conversations is key. Self‑awareness, and understanding our knee‑jerk negative response to errors is a result of subconscious bias, and is critical in managing our reactions to colleagues as well as our own mistakes.

Hindsight and outcome biases are potent factors in our judgement of others’ mistakes, and often lead us to be overcritical (Baron and Hershey, 1988; Henriksen and Kaplan, 2003).

Upskilling in human factors principles to facilitate the analysis of errors is also critically important. This discipline combines knowledge of human abilities and limitations with the design of systems, organisations, jobs, machines and tools for safe, efficient human use. In the clinical setting, this translates to appreciating the realities of clinicians’ limitations in the context of an imperfect “system” in which they work and the influence that environment has on their behaviours.

Contributory factors frameworks rooted in this concept underpin significant event investigation procedures, shifting the focus of “blame” away from individuals and on to the system in an effort to identify areas for positive change.

The black box mentality can also be extended by the power of big data. As a centralised reporting system, VetSafe can help identify common error traps, potentially providing a bird’s eye view of the major professional risk factors, trends and patterns. This nested approach to patient safety and risk management amplifies the learning at all levels of veterinary practice and holds the potential to increase the quality of care delivered at all levels in the profession.

Conclusion

Mistakes will always happen, but practices and individuals who adopt a black box mindset will be able to capture the learnings from past mistakes and transform them into better care for their patients.

Positive organisational cultures will be characterised by mutual trust and support, effective information gathering and a collective belief in learning from errors, rather than burying them.

Systems such as VetSafe could provide the platform for such a shift in thinking and pave the way for positive change.

• To learn more about VetSafe, visit www.thevds.co.uk