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Looking without Seeing

I have been a constant advocate of the Root Cause Analysis process to understand the sometimes hidden factors that lead to mishaps and bad outcomes (see “The Day the Music Died” and Pre-disasters and Halloween Ghosts of Mistakes Past).  I recently participated in one such review where an endotracheal tube was misplaced in a patient who had daily chest x-rays for three straight days that were all “looked at” but nobody noticed the problem until the patient suffered a respiratory and cardiac arrest.  The RCA was a slam-dunk as the cause was there all along for anyone who did more than “look at” the x-rays but had actually “seen” them.  It was clear from the RCA that “looking” is a process we do with our eyes but “seeing” is a much more complex process we do with our brains.

I love Sir Arthur Conan Doyle’s character Sherlock Holmes who is the ultimate at actually seeing what he is looking at.   As Dr. Watson recalls on just such an occasion with Sherlock, ‘I looked over our guest but didn’t gain much from my inspection.  Sherlock Holmes’ quick eyes took in my occupation and he shook his head with a smile as he noticed my questioning glances.  “Beyond the obvious facts that he has at some time done manual labor, that he takes snuff, that he is a Freemason, that he has been in China, and that he has done a considerable amount of writing lately, I can deduce nothing.”  Mr. Jabez Wilson started up in his chair, “How, in the name of good fortune, did you know all that, Mr. Holmes?’ he asked.  Watson then goes on to lament, “I trust that I am not more dense than my neighbors, but I was always oppressed with a sense of my own stupidity in my dealings with Sherlock Holmes.  Here I had heard what he had heard, I had seen what he had seen and yet from his words it was evident that he saw clearly not only what had happened, but what was about to happen, while to me the whole business was still confused.’

Wow, Jabez is right on, how does he do that all the time?  As Holmes proves, some things that are pretty obvious in retrospect can hide right out in the open in front of your eyes and you can look right through them if you don’t look for them.  Sherlock is the poster child for seeing with his brain not merely looking with his eyes. As students and advocates of the High Reliability Mindset, what is there to be learned from these tales and these types of incidents?  The first lesson is that of active concentration and actively paying attention.  It’s easy to be dulled into complacency and just give a cursory “look” at the same old stuff that crosses our paths day after day without paying heed to the subtle clues that there is a change in the patient’s condition.  Human factors experts group errors into active (doing the wrong thing) and passive failures (not doing something important).  Not noticing the misplaced endotracheal tube was a passive or latent failure.  This is the type of error that occurs mostly during automatic performance of routine tasks and usually the result of lack of attention and just plain boredom.  Pilots on long hours flying with the autopilot steering the bus face this; but there are ways to combat risks of mistakes during times of boredom and complacency brought on by repetitive routine tasks.

To reduce the risks of these types of errors, the FAA and human factors experts recommend saying things out loud not just thinking about what you are looking at to yourself.  The active thought process that is needed to form coherent sentences forces our brains to think through each aspect of the situation in detail, identify the problem and formulate a solution.  When we just think about things we tend to “slur” our words, and therefore our thoughts, into less precise and less exact forms that “look” without “seeing”.   Take Sherlock Holmes’ vs. Dr. Watson’s assessment of their guest Mr. Wilson as a perfect example.  Watson gave a simple once over of their guest but Sherlock started at the top of his head and out loud in a methodical way observed and commented about each detail all the way to the bottom of Wilson’s feet detailing exactly what he saw and coming up with logical explanations.

Forming an actual physical plan to guide our observations has real value and it is taught in the cockpit.  Pilots call it a “question mark scan” and exactly as the words imply we scan each instrument and indicator on the flight deck in the same physical order, pointing to each group and saying out loud what it is that they are showing us.  The scan, in the shape of a question mark, starts at the top left side of the overhead panel, proceeds across the top of the windscreen and then down the center navigation console to the flight and engine controls.  I like to touch each group of instruments and I force myself to say out loud the position of each switch and lever and what I observe.  That way I avoid potentially devastating mistakes like taking off with the flaps retracted or incorrect power settings, or landing with the landing gear still stowed in the wings.

I teach my residents the same method to look at “routine” chest x-rays on our post-op patients.  I start at the top in the midline and make them tell me what they see; when we get to the bottom of the mediastinum we trace the x-ray image up the sides to look for free air or fluid.  It works, it’s reproducible, and you don’t miss an endotracheal tube that is misplaced or a subtle pneumothorax that might get bigger in a patient on positive pressure ventilation.  This safety principle of active concentration and verbal interaction also works when examining a patient.  Call out what you see and force your brain to assign a value judgment as to whether there is a change or something you have found is a new danger to the patient.

Risks of these types of errors might well be increasing in our current age of information and sensory overload.  As teachers and advocates of the High Reliability Mindset, work on your skills of active concentration, practice them by forcing yourself to form the words that formalize your thoughts and say out loud what your eyes are looking at and your brain is seeing.  Then pass these safety skills on to the next generation of physicians and surgeons.

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  1. robert berry says

    active concentration – that’s the big idea in your current blog. Achieving it, and maintaining it is so important. Similar to your pre or inflight checkdowns I often read out loud (alone in my office) when faced with what seems to be mundane financials so that I might catch the one nugget of insightful analysis that can make a difference. The High Reliability Mindset can be applied to most any important endeavor.



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