1. Cognitive Dissonance

What is our great fear in medicine? Hurting people. Not being good enough. And when we change a process for the better it inevitably implies that our PREVIOUS way of doing things was (at least relatively) harmful. To make a minor change for the better, we might have to accept we have been hurting people, maybe killing people (or putting them at risk of death) for years, even decades! – Dr Robert Farrell.

Cognitive Dissonance — the pain of accepting ego-dystonic facts — mitigates against an open, rational aggressive cycle of process improvement.

I recently read Black Box Thinking by Matthew Syed – patient safety would benefit from everyone in healthcare reading it. Syed uses several examples of cognitive dissonance – one which really sticks in mind relates to DNA testing developed in the 1980s. Numerous convicted rapists who’d already spent years behind bars were later shown to be innocent through DNA. However instead of being released they were kept locked up – one poor chap for another 10 years – the judges and barristers who’d put him away refusing to accept he was innocent.

Syed points out that cognitive dissonance is more likely to affect those who feel defined by their decisions – to do otherwise, they believe, may tarnish their reputation. Often they’re extremely bright people, highly educated and in positions of power – he uses Tony Blair’s decision to go to war in Iraq based on the presence of ‘weapons of mass destruction’ as a glaring example.

Unfortunately the hierarchical structures in healthcare mean we are likely to suffer from this. Those further up, best positioned to bring about positive change, are the most likely to suffer cognitive dissonance.

We can combat cognitive dissonance in 3 ways:

1. Change one or more of the attitudes: We would benefit from greater education about the human factors approach. This will improve patient safety beyond the education and policy writing that healthcare has so heavily relied upon (see – the hierarchy of intervention effectiveness).

2. Acquire new information: Greater transparency and access to incident reports will demonstrate to governing bodies the frequency of similar adverse events e.g. deaths from central line related air emboli occur worldwide on a daily basis (see here).

3. Reduce the importance of the cognitions: For example – how important is it to governing bodies that we keep hazardous and unnecessary indistinct chlorhexidine in the workplace when suitable alternative preparations of chlorhexidine already exist? (see here)

Through this series of posts we’ll  provide a progress report on specific patient safety hazards illustrating the obstacles to patient safety. These reports will also be provided directly to those best positioned to implement effective solutions.

Progress Update 30.9.16:

There are thousands of unnecessary hazards in our hospitals. We have selected a handful and will work tirelessly in the interest of patient safety until effective solutions are implemented.

Indistinct chlorhexidine
– Numerous cases of death and injury have been attributed to indistinct chlorhexidine (see here). Suitable alternative preparations of chlorhexidine exist and are already used without problem in many hospitals.
– Over 270 people have signed petition requesting ban
– TGA as yet have refused to ban
– Numerous additional cases discovered in seperate reporting databases
– Sydney Local Health District removed from public hospitals
– NSW Health have been contacted to remove from other LHDs
– Request sent to TGA, ANZCA, AHQSC to enforce ban.

Valved IV fluid bags
– Non-valved IV fluid bags entrain air when disconnected. If these bags are re-spiked the air may enter patient’s blood vessels. Patients have died as a result (see here)
– Valved IV-fluid bags already exist and are used in many hospitals without issue.
– We ask that non-valved IV fluid bags be replaced by valved ones
– TGA, AHQSC, ANZCA, CEC are aware. We await their further response.

Central Lines with moulded valves
– Numerous patient deaths have occurred when central lines have accidentally been left open to air (see here)
– Central lines with moulded valves are used in several hospitals outside Australia. They reduce the risk of accidentally being left open to air.
– CEC sent out a request to industry August 2015
– An application for registration was provided to TGA in Nov 2015
– TGA registered use of equipment October 2016

Support the Implementation of Gas Analysers in Areas of Resuscitation #SIGMAR16
– Gas analysis monitors have been present on anaesthetic machines for years
– Broader implementation of these monitors in other areas of resuscitation will save lives (see here) – their presence on neonatal resuscitation trolleys will have prevented the Bankstown tragedies.
– ANZCA, AHQSC, CEC aware. We await their further response.

Draeger APL valves
– Old Draeger APL valves can be trapped open but appear closed – Patients cannot be ventilated and are left at unnecessary risk. There’s numerous reports of adverse events from the issue (see here). Draeger have redesigned their APL valves with a bevel to overcome this issue – they could replace their old valves with their newer version.
– Draeger have refused to recall. Have refused to contact users of older valves or provide heir contact details (apparently 78 old valves are left in Australia)
– TGA have so far refused to recall and have refused to send industry alert to users
– ANZCA has sent an alert (see here)

Access to incident reporting databases
– Despite entering incident reports front line staff are unable to access incident report databases (see here)
– Access to these databases is limited to governing bodies
– Numerous different error databases exist in Australia. They do not communicate with one another and are not transparent. Front line staff are unable to learn from the valuable information contained within them.
– Solutions to reported incidents often have limited if any effect in preventing future adverse events: this is the top down approach which heavily relies on education and policies (see here)
– In NSW we are comunicating with governing bodies CEC, NSW Health to allow front line staff access to the IIMS database. We will keep you updated of progress.

We thank you for your ongoing support.

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