There's an old Hindu parable about an elephant and five blind men (the number of blind men varies in different versions of the story). In the story, each blind man touches the elephant in order to describe to the others what an elephant is like. As each blind man touches a different part of the elephant, the description varies significantly, and not one description is exactly correct.
The American poet John Godfrey Saxe immortalized the story in the American lexicon with his version, which can be found here. In Saxe's version, there are six blind men. The first blind man touches the elephant's side and states that the elephant is like a wall. The second blind man touches the elephant's tusk and states that the elephant is like a spear. The third blind man touches the elephant's trunk and states that the elephant is like a snake. The fourth blind man touches the elephant's leg and states that the elephant is like a tree. The fifth blind man touches the elephant's ear and states that the elephant is like a fan. The sixth blind man touches the elephant's tail and states that the elephant is like a rope.
The "Blind Men and the Elephant" is a perfect example of how different perspectives can provide vastly different explanations of a particular event. I am reminded of a great movie, called Vantage Point, starring Dennis Quaid, Forest Whitaker, Sigourney Weaver, and William Hurt. Dennis Quaid plays a U.S. Secret Service agent trying to protect the President of the United States (played by William Hurt). The movie is unique in that it tells the same story eight different times - each from the vantage point of a different character in the movie. There was a similar movie in 1950 called Rashomon, which has given rise to the phenomenon known as the "Rashomon Effect" in cognitive psychology.
Collectively, this Hindu parable and these two movies describe the situation in which multiple perspectives can lead to multiple explanations (some of which may be completely wrong) of an event. We see examples of the "Rashomon effect" in health care today. Consider the case of a physician who commits a 10-fold dosing error with a particular medication order (note that in pediatrics, medication dosing is based on body weight, so that medications are administered on a mg medication per kg body weight basis). Why did this dosing error occur? The simplest explanation is that the physician had a momentary lapse in judgment and made a decimal point error in the calculation. Upon further review, however, the physician was in the last hour of a 36 hour shift (this particular case occurred prior to the implementation of duty-hour restrictions for residents). Moreover, the bedside nurse was relatively new to the hospital and didn't want to question the physician's authority. Finally, the medication was a verbal order (i.e. not written down - again, before the days of computerized physician order entry) and was administered in an emergency to a critically ill infant in the Pediatric Intensive Care Unit. For this reason, the pharmacist, who would have normally reviewed and filled the medication order, was not involved in the case. Multiple checkpoints for medication safety were bypassed. Had we talked to each individual - the physician, the nurse, and the pharmacist - we likely would have heard vastly different stories. Only by putting all three versions of the event together could we learn the true root cause of the medication error.
High reliability organizations (HROs) are characterized by a reluctance to simplify interpretation of events. HROs understand that we live in a complex, unpredictable world and that the easiest explanation (often the first explanation) is usually not the complete story. HROs do not fall victim to either the Rashomon effect or to the related phenomenon of "groupthink" (more on groupthink in a future post). HROs conduct thorough, in-depth investigations of adverse events, usually interviewing multiple individuals to get different perspectives, in order to get to the root-cause of the event.
We can easily see that if we relied simply on only one of the blind men's explanations, we would never fully understand what an elephant looks like. It is only by putting together all six explanations that we come close to knowing the truth. The simplest explanation (often the easiest explanation) is rarely the correct one. Dig deeper for the truth and do not simplify.
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