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Black box thinking: changing the surgical mindset Alisdair Felstead
The concept of learning from one’s mistakes is not a new one. Many of us will be familiar with the now ubiquitous comparison of the approach to safety by airlines with that of healthcare organisations. The mandated ‘cockpit silence’ for the WHO checklist shows how far we have come in healthcare regarding reducing medical errors by instituting protocols. Alisdair Felstead is currently a Senior Trauma Fellow at The Royal Sussex County Hospital in Brighton, having completed a Foot and Ankle Fellowship at Queen Alexandra Hospital Portsmouth. He completed his specialist training in the KSS region, and will soon be taking up a consultant position in Foot and Ankle Surgery.
M
atthew Syed expands upon this idea and introduces the theory of ‘Black Box Thinking’ in his excellent book1. The premise is that each of us can employ a metaphorical ‘black box’, which can be opened after an error and used to influence future practice. The key to opening the box is by supressing some of the natural human traits such as confirmation bias and cognitive dissonance, and by eradicating the blame culture that so pervades the modern-day NHS. The book begins with the account of the death of Elaine Bromiley during a routine sinus operation. This young mother was a low-risk elective patient who suffered hypoxia under general anaesthetic despite the intervention of several senior anaesthetists. The futility of the interventions, and the lack of perspective which prevented the initiation of a surgical airway, provide the opportunity for significant learning. The fact that her widower is an airline pilot has further amplified the ability of her story to change the way individuals work in healthcare. Syed argues that a ‘no blame’ culture is essential to benefit from the learning that these incidents provide. This is not to say that negligence should be ignored, more that professionals acting in good faith and under pressure should be supported to engage with the learning process, and not castigated or ostracised. Unfortunately, Syed argues, we have a long way to go in modern healthcare to achieve the safety profile of the airline industry.
20 | JTO | Volume 10 | Issue 02 | June 2022 | boa.ac.uk
This problem is not restricted to the NHS, indeed up to 400,000 deaths per year in the USA are attributed to preventable harm. The issue is the divergent approach to failure when comparing the two sectors. After an air accident, the black box will be obtained, and searched for clues as to the causative factors. Key players will be interviewed without prejudice. Sometimes simulations will be run to look at the effect of modifying individual factors. Only once the learning has been put into place will flying resume. Unfortunately, in health care we are crippled by a fear of litigation from the patient, and shame in front of our peers. Despite official protestations, the impression is given that there must always be somebody ‘at fault’, a scapegoat if you like. It has always struck me as odd and disturbing that some staff in the NHS see the obligatory Datix form as an instrument of blame. This completely misses the point of the exercise and obliterates the opportunity for learning. Syed illustrates this concept neatly referencing a Harvard study comparing two hospitals, one where a ‘blame culture’ was endemic and staff lived in fear of reprisal, and one where the environment was open and honest. The reported incidence of mistakes in the former was lower, but the actual measured level of patient harm was higher. The same effect was seen in the ‘Baby P’ case in Haringey, where castigation of the social workers led to resignations, staff shortages and the rate of child homicide increased by 25%. The message is that paradoxically, an open and honest ‘no blame culture’ leads to a safer environment for patients. >>
