O T H E R F E AT U R E S The 160-Pound Computer That Can Be Mass-Produced by Unskilled Labor Ellen S. Deutsch, MD, MS, FACS, FAAP, CPPS After three years of training, John Glenn rocketed into space aboard the Editor, Pennsylvania Patient Safety Advisory Mercury capsule Friendship 7. He became the third American in space and Medical Director, Pennsylvania Patient Safety Authority the first to orbit Earth. The historical flight was no easy feat. At the end of his Mary Patterson, MD, MEd first orbit, a yaw attitude jet clogged, forcing Glenn to abandon the automatic Associate Vice Chair, Medical Education Research in Simulation and CAPE control system and use the manual electrical fly-by-wire system.1 Children’s National Medical Center Astronaut Glenn’s landmark flight took place in 1962, supported by then state-of- the-art technology. Plans for the flight took into account the possibility that system components could fail or malfunction, with catastrophic results, so backup strategies Corresponding Author addressed the need for a manual control system.2 In fact, although the historical flight Ellen S. Deutsch overall was a resounding success, some components of the spacecraft did not function properly,1 requiring Glenn’s knowledge and skills. In accounts of the postflight debriefing, Scott Crossfield, a test pilot and aeronautical engineer,3 asked, “Where else would you get a non-linear computer weighing only 160 pounds, having a billion binary decision elements, that can be mass-produced by unskilled labor?”4 His recognition of the important capabilities of humans is relevant to our understanding of processes that support safer healthcare. In working toward safer healthcare, we seek causes for outcomes that are perceived as unsafe or are thought to be less satisfactory than might have been expected. Various investigative processes may be used, such as root-cause analysis.5 It can be tempting, and may be a fundamental psychological tendency (e.g., hindsight bias) as well as an industry norm, to try to identify the action (or inaction) of a person as a cause for an unsatisfactory outcome, despite teachings to the contrary.6 Although many of the healthcare conditions we treat are biologic and not man-made, all of the healthcare delivery systems that we work within have been created by humans. If they fail, or do not succeed sufficiently, and we search for what we think may be a cause, we are bound to find a human: The search for a human in the path of a failure is bound to succeed. If not found directly at the sharp end—as a “human error” or unsafe act—it can usually be found a few steps back. The assumption that humans have failed therefore always vindicates itself.7 Sometimes we are reminded that “to err is human,”8 or even “to err is human—and let’s not forget it.”9 Indeed, humans do make errors, and according to the Institute of Medicine (IOM), one of the greatest contributors to accidents in healthcare is human error.8 However, IOM, Lucian Leape, and others explain that human errors are often induced by system failures.8,10 It is also humans who solve problems and rescue patients, humans who figure out compensatory strategies when expected resources are not available or do not function as expected or when novel circumstances arise. People working in healthcare are among the most educated and dedicated workforce in any industry.8 Rollin J. (Terry) Fairbanks asserts that “to better is human”11 and Richard Holden states that “to blame is human, but the fix is to engineer.”6 Safety is not inherent in systems. The systems themselves are contradictions among multiple goals that people must pursue simultaneously. People create safety.6 Computers and other technologies have improved the safety and capabilities of healthcare, just as they have improved the safety and capabilities of aeronautics. The contributions of technology are integral and essential in healthcare delivery. However, when our protocols are insufficient for the tasks at hand and our technologies Vol. 12, No. 3—September 2015 Pennsylvania Patient Safety Advisory Page 123 ©2015 Pennsylvania Patient Safety Authority O T H E R F E AT U R E S malfunction, it is the human element that caring for patients within our complex the unique skills, knowledge, and even we rely on to adapt, just as the human healthcare delivery systems, there are compassion of this special type of 160- capabilities of John Glenn ensured the many aspects of care that can and should pound computer remain essential. success of the Friendship mission. When be standardized and computerized, but NOTES 1. National Aeronautics and Space 5. Deutsch ES. “What goes wrong” 10. Leape L. Cultivating and sustaining Administration. Glenn orbits the Earth (Safety-I) and “what goes right” respectful behavior. Keynote [online]. 2012 Feb 16 [cited 2015 Jul 10]. (Safety-II). Pa Patient Saf Advis presentation at: 17th Annual NPSF https://www.nasa.gov/centers/glenn/ [online] 2015 Jun [cited 2015 Jul 10]. Patient Safety Congress; 2015 Apr 30; about/bios/mercury_mission.html http://patientsafetyauthority.org/ San Antonio (TX). 2. Preparing a man to orbit. In: Swenson ADVISORIES/AdvisoryLibrary/2015/ 11. MedStar Health National Center for LS Jr, Grimwood JM, Alexander CC. Jun;12(2)/Pages/83.aspx Human Factors in Healthcare [website]. This new ocean: a history of Project 6. Holden RJ. People or systems? To [cited 2014 Nov 2]. Washington Mercury [online]. NASA Special blame is human. The fix is to engineer. (DC): National Center for Human Publication–4201. 1989 [cited 2015 Jul Prof Saf 2009 Dec;54(12):34-41. Factors in Healthcare. http:// 10]. http://history.nasa.gov/SP-4201/ 7. Hollnagel E, Woods DD. Joint cognitive medicalhumanfactors.net ch13-2.htm systems: foundations of cognitive systems 3. National Aeronautics and Space engineering. Boca Raton (FL): Taylor and Administration. NASA Dryden Francis; 2005. biographies, former pilots: A. Scott 8. Kohn LT, Corrigan JM, Donaldson Crossfield [online]. 2014 May 7 [cited MS, eds. Institute of Medicine. To err 2015 Aug 12]. http://www.nasa.gov/ is human: building a safer health system. centers/armstrong/news/Biographies/ Washington (DC): National Academy Pilots/bd-dfrc-p021.html Press; 2000. 4. An American in orbit. In: Swenson 9. Croskerry P. To err is human--and LS Jr, Grimwood JM, Alexander CC. let’s not forget it. CMAJ 2010 Mar This new ocean: a history of Project 23;182(5):524. Mercury [online]. NASA Special Publication–4201. 1989 [cited 2015 Jul 10]. http://history.nasa.gov/SP-4201/ ch13-4.htm Page 124 Pennsylvania Patient Safety Advisory Vol. 12, No. 3—September 2015 ©2015 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 12, No. 3—September 2015. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2015 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (MCARE) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s An Independent Agency of the Commonwealth of Pennsylvania website at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and indepen- dence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions. 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