Failure mode and clinical practice: is there any relationship?

breast cancer1Pericardial and pleural effussion in breast cancer

Failure mode is a quality control technique used in the industrial environment as a way to reduce “failure” related with systems and hardware. The rationale is to predict possible malfunction areas  in a machine and select the causes. We believe that  this approach can be adapted to medical education  to teach how to prevent harm in a patient and, at the end, to improve diagnosis…

The interaction between human anatomy and function, result in  clinical situations that leaving undetected even for a short time, are deletereous for the patient. Perhaps an increase of intracranial pressure is the most dangerous of these situations. We are not saying that this syndrome is not explained in medical schools, what we want to clarify is that teaching about this emergency in terms of “possibility” in different clinical scenarios can help to detect them before harm is established.

Some other examples follow:

– increase intraocular pressure: ophtalmologist are used to measure intraocular pressure, but they are the last step. Medical students and juniors doctors must be aware of the complicated equilibrium between liquid production and absortion through the ciliar area. This is an anatomical location very prone to “failure” with the dramatic consequences in terms of optic nerve failure.

– Kidney function:  kidneys are organs very sensitive to different situations and the possibility of failure is very high. Not only hipovolemia or dehydration, also an increase of pressure around the pelvis or ureter, can result in “failure” without  symptoms of alert.

– Pericardial effussion: the presence of symptoms is related to the amount of liquid inside the pericardium. Patients can suffer a deterioration just in minutes with cardiac failure. Pleural effussion yield similar situation but usually is more predictible.

– Mediastinum: an increase of pressure due to pneumomediastinum has a direct influence over the cardiac function. In a recent paper in “The Lancet” a new diagnostic radiologic sign called “the earth-heart sign” has been described as a finding related to an increase of pressure over the myocardium(Gerardo Andrés Obeso Carillo,Gonzalo Barge Caballero, Miguel Ángel Cañizares Carretero.

Lancet 2014; 383: 486

Teaching using failure mode techniques in different clinical situations will have in our opinion a direct influence over the clinical reasoning of doctors, helping to diagnose in advance dangerous situations where time is gold.