By Alessandra Suuberg, Decency LLC
I recently came across a podcast episode describing the “series of unfortunate events” that can happen in EMS (emergency medical services).
In some cases, these chain reactions lead from small, seemingly innocuous decisions to devastating, even fatal, patient outcomes.
The hosts described one case where an ambulatory patient had asked not to be taken to the hospital on a board, asserting that he would vomit if lying flat. Against his objections, the paramedic in that case insisted on spinal immobilization, and the patient finally agreed. As (partially) predicted, the patient then vomited in transit, aspirated, became hypoxic, coded, was resuscitated with anoxic brain injury, was discharged to a nursing home, developed a bed sore, developed sepsis, and died within two months.
Reflecting on examples like these, the podcast hosts noted that EMS professionals may not even realize how their small mistakes are snowballing into serious outcomes.
And this makes sense, given that healthcare today is a complex and notoriously siloed system.
Complex Systems and Cascading Failures
In general, complex systems are vulnerable to “cascading failures,” where an error or “failure . . . increases in size over time due to a positive feedback loop.”
This can be seen in the context of financial networks, power grids, and computer networks.
At one end of the spectrum, small mistakes might “mind their own business” without causing big problems. At the other end, they might create a “domino effect of increasing failures,” when a small mistake in one part of the system leads to another or feeds into additional mistakes in other parts of the system—a “cascading failure” that causes network outages or threats to patient safety, depending on the context.
How Does Healthcare Handle Snowballing Mistakes?
In the above-mentioned podcast episode, one host opined that the more experience he gains, the more restraint he practices, in order to avoid negative downstream effects for the patient.
Elsewhere (2013), healthcare providers have opined on the importance of making sense early of the events that lead to medical mistakes. Other providers (2004) have highlighted the role that miscommunication plays in propagating errors.
More recently, in 2020, one researcher described a cascading or snowballing effect in the realm of medical testing, where one medical test can spur “phone calls, office visits, tests and treatments, each a logical, even inevitable, progression from the one before.” According to the researcher, a majority of 400 physicians surveyed said that these types of cascades were harming their patients “at least several times a year.”
Her conclusion: doctors “need better ways to navigate cascades once they begin.”
Disclaimer: The information and opinions on this site do not include legal advice or the advice of a licensed healthcare provider.