Intelligent accidents

May 26, 2009
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“Adults do the darndest things!” exclaimed OSHA chief Edwin Foulke, kicking off a May, 2006 speech to the Association of Georgia’s Textile, Carpet and Consumer Products Manufacturers.

OSHA’s boss brought pictures to prove it. There was a fellow standing with one foot on an unstable ladder, which leaned against power lines. An ”overconfident character” sat beneath a propped-up truck, “just waiting for trouble to come crashing down,” said Foulke. A forklift lifted another forklift, which carried two guys with “no safety harnesses, no hats, no concerns,” he said.

“And our first place winner for unsafe work practices goes to this guy overseeing a team of people fully-dressed in hazmat gear,” said Foulke. “He looks surprisingly calm while wearing no safety protection. I hope he at least wore sunscreen!”

Can we chalk up Foulke’s gallery of bloopers to foolishness, lack of training, reckless disregard for rules, or plain stupidity?

When union safety leaders got wind of Foulke’s speech and lamb blasted him for “blame the worker” finger-pointing, the headline in the Washington Post became, “OSHA Does The Darndest Things.”

Now was Foulke’s political faux pas due to foolishness, lack of training, or reckless disregard for political correctness? Plain stupidity? Doubtful, the man has a master’s degree in law from Georgetown University Law School and was a member of the Occupational Safety & Health Review Commission for five years.

“WHAT WAS I THINKING?”

The August issue of National Geographic Adventure magazine attempts to answer this puzzle in an article: “Why Smart People Make Dumb Mistakes.” Or as the author says, “Where was my mind when I needed it most?”

Why otherwise rational, well-schooled people do the irrational at times is a hot topic in medicine these days, with the growing patient safety movement putting the spotlight on misdiagnoses, why many docs refuse to wash their hands, and sometimes will operate on the wrong leg or wrong patient altogether.

Two recent books explore the underdeveloped cognitive side of medicine: “Better – A Surgeon’s Notes on Performance,” by Atul Gawande, M.D., and “How Doctors Think,” by Jerome Groopman, M.D.

It turns out surgeons, rock climbers, assistant secretaries of federal departments, airline pilots and fork lift operators all can succumb to intelligent mistakes and accidents, of course when least expected.

Dr. Pat Croskerry examined a forest ranger complaining of a pain in his chest one spring afternoon in an emergency room case related in “How Doctors Think.” The ranger was in his early 40s, trim and extremely fit, a wiry, muscular man, Dr. Croskerry noted. The doctor went over the list of risk factors for heart and lung disease. The man never smoked, had no family history of heart attack, stroke, or diabetes, and lived anything but a sedentary lifestyle.

Dr. Croskerry then performed a physical examination. Vital signs were normal. Everything sounded fine. An electrocardiogram, a chest x-ray, and blood work – all were normal.

“I’m not at all worried about your chest pain,” Croskerry told the ranger. “You probably overexerted yourself in the field.”

The next evening, Croskerry arrived in the emergency department and bumped into a colleague. “Very interesting case, that man you saw yesterday,” the doctor said. “He came in this morning with an acute myocardial infarction.”

BLINDED BY FEELINGS

Croskerry was stunned. He realized that he had made a common cognitive error, one that could have been fatal. He didn’t miss it (what in retrospect was unstable angina caused by coronary disease that usually comes before a heart attack) because of any reckless or lazy behavior. His thinking was overinfluenced by how healthy this ranger looked.

“The effects of a doctor’s inner feelings on his thinking get short shrift in medical training,” writes Dr. Groopman in his book. Physicians rarely recognize and reflect on how other emotions influence a doctor’s perceptions and judgments, he says.

Feelings, emotions, prejudices, and blinders afflict far more than physicians. In December, 2006, three experienced, well-trained climbers ignored obvious clues that the weather on Oregon’s Mount Hood was deteriorating, sparking one of the largest rescue missions in the state’s history. The climbers were eventually found dead.

“We really don’t perceive the world most of the time,” writes Laurence Gonzales, the author of the National Geographic Adventure article. “Most things eventually fall into the category labeled ‘ignore’.”

In the workplace, this allows us to get our work out of the way, finish the shift, and hightail it home – without having to stop all the time and reexamined something. We conveniently deposit potential hazards, dubious circumstances, signs of risk into the “ignore” box because we’ve been lulled into complacency. We’ve not had to pay for our ignorance in the past. Our experience, success or luck shapes our behavior, writes Gonzales.

NOT MY PROBLEM

Attitudes can also warp our vision. It’s easy today to believe that someone else is responsible for our-well-being, discouraging us from taking responsibility for ourselves. Johnny gets bad grades, it’s the teacher’s fault. Jenny can’t crack the starting line-up, it’s the coach’s fault. A physician mishandles a surgery, sue him.

At work, we can come to see others as being responsible for our safety – the maintenance guy, the safety manager, the safety team, OSHA inspectors, the big boss plant manager. All of this social conditioning, from the time we’re young, encourages us to drop our guard and look for someone to blame when things go wrong.

How many banners or bumper stickers have you seen proclaiming, “THINK SAFETY”? But intelligent people can blunder into accidents because they must SEE SAFELY before the mind knows what to think.

New to his job, OSHA chief Foulke did not “see” the union critics who would attack his slide show as cold, blame-the-worker stuff.

Dr. Croskerry did not diagnose the forest ranger’s unstable angina because he saw before him a trim, muscular, fit man, and the doctor chose to ignore other signals.

Would the three Mount Hood climbers more clearly have seen the predicament they were in if they each wore emergency locator beacons, as later required by Oregon law, so rescuers could find them more easily? They might had been lulled into false security and seen no reason to worry – similar to how ship captains seized on radar when it was first introduced to drive their boats faster, according to Gonzales.

SEEING SAFELY

“One of the most useful things I learned in survival school,” writes Gonzales, “came from watch my instructor.” While Gonzales was eager to blaze ahead through the woods, his instructor seemed stuck in slow motion. He ambled along, looking at flowers, and was in no hurry. “I realized… he was slowing down and paying attention. He was allowing himself to have second thoughts,” because first thoughts arise through the recall of past experience, not true unfiltered thinking.

Here’s the intelligent thing to do: “We should strive to slow down and examine what we are really doing,” says Gonzales. “Yes, I tell myself. It can really happen to me. It’s out there waiting for me now. It will come unannounced.

“Success in the wild… lies in the willingness to stop and question what you’re doing,” says Gonzales. The same holds true anywhere men and women are at work.

By Dave Johnson, Editor, ISHN

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