Humans are fallible, prone to making mistakes. Understanding and accepting our fallibility as a reality is the first step in building a culture.safer health. Most people know how to identify a mistake when it is made or observed. However, there are many definitions of error in the literature, here we will base ourselves on the following definition of medical error: “Medical error is the failure to correctly apply an action plan as proposed, or the use of the wrong plan to arrive to the proposed goals. ”
In other relevant definitions, we have: quasi-failure which is defined as “any variation of the process that did not affect the result, but that with a recurrence runs a significant risk of a major adverse event.”
A sentinel event is defined as “an unexpected event, involving death or serious physical or psychological injury, or the risk of it happening. A serious injury specifically includes the loss, or loss of function, of a limb. Any variation of the processes is included, in which their recurrence can present a serious adverse event. These events are called sentinels because they require immediate investigation and response. ”
With a defined medical error definition, you can start analyzing why we make mistakes. When something goes wrong it is usually always attributed to human error. Once the human error is blamed, the investigation usually stops. But it shouldn’t stop, at least not if the goal is to eliminate the error. Why the human could make that mistake or how the system or the device failed to prevent the human from making the mistake must be investigated.
Although we are fallible, people are often not responsible for mistakes. This is because people have systemic biases in the way we perceive the world around us. For example, right-handed people are likely to turn right when entering a new place, even if it is not the best route. Also most people show a preference for the number 7, or the color blue. Expectations can also shape the way we perceive the world, and the way we act. The effect of these biases occurs mainly unconsciously and are difficult to correct.
TAKE THE GOOD WITH THE BAD
Many of the qualities that allow humans to do so many things so well have a flip side that makes mistakes. The first area is the ability to quickly assess a situation; We can identify the situations in which we find ourselves almost immediately. Unfortunately, a lot of the details are lost in this quick scan. The problem with this is that we usually think that nothing escaped us, so visual errors are made.
This happens quite frequently in the field of medical malpractice. What usually refers to hindsight bias is the “wrong attribution of guilt”, one of the same mistakes that are made over and over again, and there is no learning from experience. In hindsight, our understanding is always much better because the factors involved in the error are obvious when viewed in retrospect, even when they are not at the time of error.
When we see the cause of an error it is very important to look at the environment and the support systems around humans. For example, if someone has a car accident to come sending messages on the cell phone, it is about changing the system; Now there are cars that allow you to write messages without having to have your cell phone in your hands or stop seeing the road.
By getting a better view of the things we do well and the things we do wrong, it is easier to do them well.
Some other reasons why we humans make mistakes or are more likely to make them are:
- Lack of sleep (casinos love this reason, as people tend to make riskier bets when they are tired. This explains why casinos are open 24 hours a day, 7 days a week).
- Being unhappy (Humans function best when we are happy. Happiness encourages well-organized thinking and flexible problem solving).
- Being overly optimistic (Humans have a false sense of confidence when making decisions. This overconfidence when making decisions is one of the main causes of human error).
- We depend on memory (memory is more of a reconstruction than a reproduction, so it is not as good as humans think. This is why place and surroundings are so important when trying to remember something).
A better understanding of the aforementioned reasons why humans make mistakes can lead us to improve the quality of medical care, as well as to apply better prevention techniques.
Dr. Bernardo Rea Ruanova *
Clinical Risk Manager
Grupo Mexicano de Seguros
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How to understand the mistakes?
Mistakes are favors that life gives you so that once and for all you start your way. Today we bring you 20 phrases that will help you better understand mistakes.
- Don’t waste a good mistake, learn from it. Robert Kiyosaki.
- The biggest mistake people make is not making a living doing what they like best. Malcolm Forbes.
- Avoiding the situations in which you could make mistakes can be the biggest of all your mistakes. Peter McWilliams.
- Experience is simply the name we give to our mistakes. Oscar Wilde.
- No matter how many mistakes you make or how slow your progress is, you’re still way ahead of those who don’t try. Tony Robbins.
- Success is not about never making mistakes, but about not making the same mistake a second time. George Bernard Shaw.
- Those who do not make mistakes are making the greatest of all: not trying anything new. Anthony de Mello.
- A failure is not always a mistake. It may simply be the best thing to do under those circumstances. The real mistake is to stop trying. BF Skinner.
- I have learned that the best lessons came from my biggest mistakes. Gurbaksh Chahal.
- I think the biggest mistake is giving up too quickly. John Kremer.
- Take risks, make mistakes. This is how you grow. Pain nurtures courage. You have to fail in order to practice bravery. Mary Tyler Moore.
- You must learn from your mistakes, but not rely on your past successes. Denis Waitley.
- Mistakes are part of life; you can’t avoid them. The only thing we can hope is that they are not too expensive and not to make the same mistake twice. Lee Iacocca.
- A mistake does not have to govern a person’s entire life. Joyce Meyer.
- Forgive yourself for your failures and your mistakes and move on. Les Brown.
- I was taking myself very seriously when I was going through life changes. And I realized that I needed to laugh at myself, particularly at my mistakes. Spencer Johnson.
- Some mistakes have more important consequences than others. However, you should not let the result of your mistakes define you. You have the option of not letting that happen. Jojo Moyes.
- We learn by falling. If we never fall, we will never walk. Robert T. Kiyosaki.
- I’m glad I didn’t pay attention to the good advice. If I had been guided by them, I would have been saved from the most valuable mistakes of my life. Edna St. Vincent.
- Taking a step back after taking the wrong path is taking a step in the right direction. Kurt Vonnegut.