Social Safety Swiss Cheese

I want to use the swiss cheese model to talk about how we create and maintain layers of imperfect social safety in our clinics. It’s also worth revisiting what Lisa said about the difference between adverse events and errors. Specifically, that not all adverse events are due to an error, and not all errors cause an adverse event. Lisa shared that 26% of the adverse events reported to the database involved a stray or forgotten needle. I’m going to talk mostly about errors I’ve made that do not involve any needles at all, and yet most certainly carried the potential for “a negative consequence or injury to a patient” when considered through the lens of trauma-informed care.

Again, here is this excellent list of common trauma triggers in healthcare settings, according to Laurie Lockhart MS:

authority figures
sensory cues of past events
lack of power/control
feeling threatened or attacked
caught by surprise
feelings of vulnerability and rejection
sensory overload
 Shaming

These triggers are all things that can compromise a patient’s social safety, and the swiss cheese metaphor works really well to help us think about how to create more safety. Social safety errors in clinic will happen, and I can think of three reasons for this: One is that I, as a practitioner, have unchecked biases living in my head. Second, these biases are cohabitating alongside my own trauma triggers, which can cause me to mis-read what is happening in any particular triggered moment and therefore respond inappropriately. A third is that trauma triggers are really like a minefield we enter whenever we’re working with patients. They are cruelly specific at times, and wickedly unpredictable to outsiders, and there is no way to avoid them all. There is also no way to connect with another human without traversing that minefield. That risk is the cost of intimacy, at any level.

I’ve made a good number of social safety errors over the years. The reason I want to talk about them is that, (even though my professional liability insurer is not interested in these), these errors interfere with my goal of creating accessible healthcare, and these are places I can do better; things that are under my control.

I have mistaken one patient for another and called them by the wrong name. Repeatedly. I have misgendered people.

caught by surprise
feelings of vulnerability and rejection

I have assumed the wrong relationship between people. I once had these two patients who always came in together and were very sweet to one another. I treated them both for years. They each wore a wedding ring, and one was a man, the other a woman (cue the heteronormative bias that presumes a romantic relationship between any two cis people of opposite genders seen together). One Friday, I asked:

“So what are you two up to this weekend?”

“Oh, we don’t… we’re not… We work together”

caught by surprise
feelings of vulnerability and rejection
 Shaming

I’ve also made any number of acupuncture errors that could undermine a patient’s confidence, such as treating the wrong limb,

caught by surprise
feelings of vulnerability and rejection

needling points that a patient had specifically requested I avoid,

authority figures
sensory cues of past events
lack of power/control

using too many needles,

sensory overload
lack of power/control

and (ahem) completely forgetting to place any needles at all. I discovered this when the patient woke up and I went to unpin her. I’ll tell you that story, because it’s a good one, and it helps think about swiss cheese and social safety. For context, I was a new parent, bleary-eyed, overwhelmed, and exhausted. There’s the self-care layer of swiss cheese safety. I was not on top of that.

This patient was a regular. She was managing Hep C by juggling a few different medication protocols and using a lot of acupuncture. The treatments were very helpful, but she couldn’t afford the sliding scale. So we had a deal where she would buy a ten-punch pass for $70. That worked great. We’d been doing this for quite a while, so she was very comfortable at the clinic and we had good rapport and communication. We’d also had practice at talking about difficult things, because she really wanted to be able to take off her pants for treatment. And that’s not allowed in my clinic. So we had to talk about it, a couple of times. In shorts weather, I used a Master Tung point combo called Three Yellows to treat her Hepatitis. It’s a great set of points for the Liver, located on the upper inner thigh. When her clothing made those points inaccessible, I’d switch strategies to other, also great, points at the extremities.

So, we had built good rapport and a nice rhythm to our work together. On this particular day, she arrived for her appointment and the clinic was hopping. I knew she would have a fairly extended health update for me, and it was important to her to say all those things before I started needling so that she felt confident the treatment was responsive to all of that info. So I let her know she could settle in and I planned to take care of a few more folks before committing to the few extra minutes she would need. She covered up with a blanket and promptly fell asleep.

My normal process is to place blankets after needling, and so when I looked around and saw a room full of sleeping, covered patients, I switched to charting mode. An hour later when she woke up and we both realized what had happened, I apologized. But she still felt hurt, and understandably so. She was an easy-breezy spirit with the deep tan of someone who spends a lot of time outdoors, a raspy voice even when whispering, and a ready smile. She would tumbleweed around to various retreats as far away as Peru, and then would be back in California doing art. She was angry with me that day, but we talked it through. I didn’t excuse my mistake or mention how tired I was. She wasn’t the type to notice, and it wasn’t her responsibility to. We both kept a good boundary there. She felt neglected, rightly so. I apologized a few times. I offered her needles right then, but she didn’t have time. I added a punch back to her card. She continued to come for acupuncture until my own tumbleweed rolled out of California.

The primary layers that allowed us to navigate past that incident to continue a productive treatment relationship were rapport and communication. Those were really significant in the moment, but those would not have been possible without some foundational decisions that allowed the relationship to develop and thrive in the first place. If we look at the Organization layer of swiss cheese, there are some important things to see there about how the clinic was originally set up to promote social safety. If it had not been set up just so, there would have been no relationship to preserve. She would not have set foot in the door.

I have a lovely opportunity to revisit these setup issues currently, as I get ready to open a brand new clinic. I have not been in practice during the pandemic and my family and I are moving. Since I am starting over in a new town, I have the chance to revisit some foundational decisions, and I can talk through the safety layers I’m setting up:

Where is my clinic [I don’t want to be in a medical/professional building]? What part of town is it and who [class, race] feels comfortable here? Is it served by a bus line?

authority figures
feeling threatened or attacked
feelings of vulnerability and rejection
 Shaming

What will I name the clinic? [Who is it for? What happens there?]
authority figures
feeling threatened or attacked
caught by surprise
feelings of vulnerability and rejection

Logo imagery and colors [welcoming across the gender spectrum], website design [accessibility], photos [body type, shape, color, ability], and language choices [plain language, hablo Espanol]
feelings of vulnerability and rejection
sensory overload
 Shaming

Decorations, furniture, lighting, and music [healthcare settings are overwhelmingly bright, cold, loud, and sterile - let’s not trigger any of that if we can].
sensory overload
sensory cues of past events

In summary, errors will happen, and traumas will be triggered. But these events don’t need to cause harm if we use a swiss cheese model to establish foundational decisions and to develop systems and practices that emphasize organization, communication, boundaries, and self-care.