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Sun May 10 00:03:56 BST 2009

Dear all,

As Mike Sise says, human factors in errors include
1. familiarity or senior experience 
2. distraction 
3. fatigue.

I am "old school" trained and have worked very long hours.  By my
non-medical colleagues standards I still do.  I have been fatigued and I
have made mistakes.  All humans make mistakes. 
- We see road trauma every day where fatigue is a contributing factor. 
- Objective evidence suggests working long hours contributes to fatigue.
- I note there is also clear evidence that mistakes are associated with
handovers.  

I do get concerned when I hear us using the "handovers are dangerous"
argument to justify doing something else dangerous - working ridiculously
long hours.  Maybe the answer to "handovers are dangerous" is the same as
the answer to other dangerous things in medicine - re-engineer them to make
them safer?   There is also quite a lot of work in this area with good
evidence that a systematised handover process improves patient safety.

Of course, as my title suggests, one alternative to avoid handovers is to
never go home and never go on leave.  I have been guilty of trying this
approach in the past.  Strangely it did not provide a long term solution.  I
note in passing that I do however have an ex-wife.

In the past my own unit has had trainees come in as trauma victims after
being injured on their way home from a long shift.  This is not good.  Our
registrars (residents for US colleagues) now work three shifts a day.  The
shifts have significant overlap to hopefully allow for good handovers.
Formalisation/systematisation of handover methods continues to improve.  We
also offer the registrars vouchers for taxis if they are fatigued,
especially after a night shift.  Despite the warnings of dire consequences,
it all seems to be working.  Our trainees seem happy enough with it and
importantly, although there is no proven causal link, I note that since we
introduced this practice our SMR has gone down.

In recent years a number of Nobel prizes in Economics have been given to
people working in the field of Behavioural Economics.  Essentially this
field recognises that humans, even when money is involved, do not behave in
a logical and rational manner.   Rather we use rationalisations to justify
doing what we emotionally want to do.  I suspect that anyone who believes
that people behave rationally in the financial world has not been watching
the Stock Market lately.

Can I politely ask therefore that we please stop using the "handover is
dangerous" argument to justify/rationalise another dangerous practice?
Maybe the "long hours people" (including me, although I working on a cure or
at least palliation ;-) ) need to admit we do it because we want to do it,
or at least we want to do it too much to be able to achieve the
alternatives.

Regards

Bill 

A/Prof William Griggs AM
Director Trauma Services
Royal Adelaide Hospital
william.griggs at health.sa.gov.au

P.S. As an addendum, some years ago I asked a US Orthopaedic Surgeon friend
of mine, who I was visiting at his home for the fourth time, why he did not
ever come to visit me in Australia.  His answer was that despite his huge
income (by my standards) he could not afford to, as he needed the $40,000 he
made each week to cover his costs, which included two ex-wives, 5 children,
his rooms, medical insurance etc.  Some years later it finally all caught up
with him.  He told me he was tired of it all and he abandoned medicine
altogether. He went off to pursue another love, training as a chef.  Of
course the financial implications were huge but he said he was much happier.
He found a solution to his stress/fatigue.  

Unfortunately for some of my other colleagues, the "solution" they found has
been suicide.  While one can never know the reasons, in each case work
stress appears to have been one factor.

Please be safe and look after yourself and your colleagues.

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"Handovers are dangerous" so I never go home or go on leave...