When It Comes to Safety and Everything Else the Devil is Always in the Details

Everyone interested in patient safety and patient care should read this article on the Washington Post blog “How Healthcare.gov looks to a health  IT Pioneer.” 

The interview with Fred Trotter, the IT pioneer in question is very revealing.  According to Trotter, a lot of things that seem obvious in retrospect were not done.  But what really hampered the Obamacare effort, he says, is the failure to pay attention to the mundane but critical details of launching such a complex venture.  Also, the government would have had to do a lot of inventing to do something new.

Here’s what Trotter says about the details: “When you get a certain amount of traffic going to any site on the internet a single computer can’t handle it. In order to handle tremendous amounts of traffic you have to have more than one computer sharing a task. At modern sites like Amazon and Ebay and Google, the main innovation they’ve pioneered is using lots of computers at the same time to answer one query to the web site.

But it’s a different problem for different tasks. If the federal government wanted to sell billions of books online that’s fairly understood. They could just look at Amazon. But they’re trying to do something entirely new. And that means that what they’re talking about is the invention of something new. The way Congress looks at software is that there are these sites that do these amazing things and we should do that, too. They don’t realize that a tremendous amount of invention has gone on at these scaled web sites to handle these processes.”

Here’s what he says about invention: “They screwed themselves twice. The first thing they did that was very foolish was to go at scale. Usually when the government understands the problem of that they do things in phases. They didn’t draft everyone for Vietnam all at once. That’s the model they should’ve used. They should’ve said people born in January can now get health insurance. Then it should’ve expanded to everyone born in the first quarter. And so on. But they presumed scale was easy. That was the first mistake. The second was assuming invention was easy. And scaling something that hasn’t been invented yet — that’s technological suicide. ”

When I read this, I was reminded of other areas of healthcare where the devil is also in the details and people are both overly optimistic and overly simplistic about what it means to create changes that are enormously complex.  I think for example of nursing care, where people think it’s all very simple and don’t understand the complexity of the banal.  They think it’s easy to feed someone who can’t feed themselves, but forget that it’s actually not so easy to feed someone who’s had a stroke.  And if you don’t know how to do it the person can become malnourished and not recover.  Or consider the new facts that have been discovered about the prevention of ventilator associated pneumonia (VAP).  Turns out the one of the best ways to prevent VAPs in ICUs is to do oral care.  Who does oral care? Critical care nurses.  And it’s not so easy to do this, Canadian critical care nursing expert Craig Dale who has studied this complex activity tells us.  Brushing the teeth and providing oral care for those with a ventilator snaking down their throats is not the same as brushing your teeth or doing oral care on a healthy person.  Again, it’s all about putting theory or grand ideas into practice, which is always tricky and much harder than you think.  (Let me tell you, after writing 17 books and hundreds of articles, I know that getting a great idea, and turning it into a book or even 750 word oped always turns out to be a lot harder than I think it will be.  And all that pales in comparison with the changes we want to implement in healthcare.)

What is missing in our great plans is often what I think of as an imagination for practice.  This is particularly true when it comes to patient safety and the prevention of medical errors and injuries.  We think about some grand scheme and simply ignore what it will take to put it into practice.  Part of this failure of imagination may be the amazing human capacity for denial.  If we really imagined the complexities of doing something, we might end up getting so discouraged we would do nothing.  Part of it is a way of dealing with naysayers, or those who present obstacles in our path.  Don’t worry, we shrug off objections, it will be way easier than you think.  But I again come back to our failure to respect the complexity of practice and what seem to us the fascinating complexity of what we often think of as something simple or banal.  In healthcare, it is often the simple or the banal that kills or injures people.  The surgeon does a great job in the OR but the patient is harmed because no one walked them and they got a DVT, or no one did mouth care and they got a VAP, or no one washed their hands and they got a hospital acquired infection.  When nurses or non-physician healthcare professionals or workers tell their stories, they often begin by saying that what they do are the “little things,” in healthcare.  When I hear that phrase “little thing,” my ears always perk up because I have learned from years of observation, that when it comes to healthcare there is literally no such thing as a “little thing.”  The little things often turn out to be the big things that hurt and we need to respect them and pay as much attention to them as we pay to what we consider those “high level” acts of medical heroism.  When it comes to patient safety and medical errors, medical heroics don’t work if the little things don’t reserve the respect they deserve.