Download PDF: FL Communiqué October 2016
Guest Editorial
Editorial
Case: Blind obedience
Problems with protocols
Use of protocols in healthcare organisations
Checklist use and philosophy – aviation
Comments from our peers
Welcome to this edition of the Communiqué in which we discuss the benefits and potential dangers of medical protocols. To illustrate this we include a case review of the death of a patient that occurred in part, due to the strict adherence of local protocols.
A clinical protocol is a rigid set of instructions for the investigation and management of a specific clinical scenario. The introduction of protocols into health care originated from the aviation industry. There, aircraft safety was dramatically improved as early as the 1930s through the systematic introduction of checklists and protocols.
The experience of the aviation industry exemplifies many of the benefits of a rigid, systematic approach. Firstly, protocols act as a checklist to ensure that important steps in management are not overlooked. Secondly, they allow for less experienced practitioners to manage patients in an appropriate way until more senior assistance is available. Thirdly, where there are several potential, equally valid management options, protocols create a consistency that gives all members of the clinical team greater familiarity with a particular approach, and so, reduces the risk of human error in the implementation of care.
Fourthly, the rigid nature of protocols creates a very clear plan. It can also be printed and easily handed over between different shifts of treating doctors and nurses. The set instructions expedite the investigation and management processes, and the various components of the plan are clearly divided, and roles allocated to the treating team. Unfortunately, the very strength of a protocol is its key limitation. Strict adherence and ongoing reliance on protocols can create a number of potential problems. Protocols are designed with a generic patient in mind and hence, may not be equally applicable or appropriate for every patient. The use of protocols may create a false sense of security and confidence in less experienced medical staff. This may lead them to overlook or ignore signs of deterioration and so fail to call for help. An inadvertent consequence is that reliance on protocols may detract from the overall development of clinical reasoning in junior medical staff.
The erosion of clinical or situational reasoning is an issue being faced by the heavily protocolised aviation industry. Protocolisation has reportedly eroded pilot expertise leading to de-skilling of pilots, to the extent that the US Federal Aviation Administration has issued a Safety Alert mandating pilots should gain more manual flying experience – this would be synonymous to practicing medicine without protocols.
This situation was highlighted in the Air France flight, AF447. In 2013, an A330 crashed into the Atlantic Ocean killing all 228 passengers and crew, after the air speed sensor iced-over. The pilots in this situation were likely task saturated, unable to respond appropriately to the dynamically changing situation, resulting in loss of situational awareness. Effectively, the pilots did the precise opposite to what should have been done given the available information.
Similarly, some academic and clinical commentators have suggested that heavy dependence on protocols among medical trainees have meant that they, “forget, or never learn to be a physician and make judgments”1. The aviation industry has taught us the great potential for improving safety through the use of systems and checklists, perhaps it is now time that we also heed their warnings about over-reliance on such systems.
1 The Land of Protocols http://lifeinthefastlane.com/land-protocols/Dr Rick Abbott, Life in the Fast Lane.