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Mistakes and how to reduce them: (Second of three parts)

Martin, Robert L.

doi: 10.1097/

Robert L. Martin, PhD, has been a Dispensing Audiologist in private practice in the San Diego area for more than 30 years. He has been writing Nuts & Bolts since 1989. Readers may contact Dr. Martin at 7750 University Avenue, La Mesa, CA 91941.



Last month I discussed the book Why We Make Mistakes, by Joseph Hallinan. It has helped me understand that people—audiologists and hearing aid specialists included—make many mistakes. The tendency to make mistakes is a quirk of human nature. “Simply put, most of us aren't wired the way we think we're wired. But much of the world around us is designed as if we were,” says Hallinan, “We are asked, for instance, to memorize countless passwords, PINs, and user names. Yet our memory for this type of information is lousy.”

Last month I talked about errors that result from overconfidence, intimidation by authority, and lack of organization. This month I want to discuss software—the software hearing professionals use to fit hearing aids and the software we use to order them. But first let's take a look at another type of professional: anesthesiologists.

Hallinan says, “Much of what we know about why we make mistakes comes from research in fields where mistakes cost people their money or their lives: medicine and the military, aviation and Wall Street.” For many years, he notes, “anesthesiologists had a terrible record in the operating room. Their patients often died ghastly deaths.” Long ago, two companies manufactured most of the machines used by anesthesiologists. On one machine the “on-and-off” dial worked clockwise, on the other counterclockwise. Many serious mistakes were made turning the dials.

This continued into the early 1980s when skyrocketing malpractice rates and bad PR forced the profession to do something. Anesthesiologists put pressure on the manufacturers to agree on standardized controls. With a lot of hard work, anesthesia deaths were reduced from about 1 in every 5000 patients to about 1 in every 200,000 to 300,000.

This reminded me of all the different programming cables and software used in our profession. It is impossible to stay current, professionally competent, with four or five different manufacturers. It is hard enough to retain a high level of competence in programming hearing aids for just one major manufacturer! This needs to change.

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I believe that manufacturers in the hearing industry need to standardize all the cables used to attach hearing aids to the computer so a single set of cables could attach your system to every hearing aid on the market.

There should also be a standardized format for hearing aid programming software. Regardless of the manufacturer, the first two menu screens should be the same simple controls so dispensers can adjust the gain and frequency response of any hearing aid.

The software should include a short checklist that we mark off when we complete basic checks for: (1) feedback, (2) adequate amplification, (3) adequate control of loud sounds, and (4) good word understanding. This screen could print a “Certificate of Quality” to show the patient we've finished these four tasks.

In his MarkeTrak reports, Sergei Kochkin has reported that there are about 1 million hearing aids in the drawer. Yet, nearly all of us believe we do excellent work, not average. It is human nature to exaggerate our abilities and underestimate our weaknesses. Our profession, like every other, is generally unaware that we need to do a much better job and make fewer mistakes. What causes us to make mistakes? Here are some of the most common reasons:

  • We don't follow our teachers' instructions.
  • We fail to read instruction manuals.
  • We do not ask for directions (well, at least the males don't).
  • We charge ahead regardless of the risks involved.
  • We don't take the time to understand our errors.
  • We accept the fact that we make many mistakes.

Hearing care—like other professions—talks about quality control. Yet we don't exert enough effort to make sure all the hearing aids we fit are worn, not put in a drawer.

It is not enough to pay lip service to quality. We need to recognize that humans make mistakes routinely and then re-engineer the system to markedly reduce them. Continuing education needs to be re-structured. Rather than listening to someone tell us how great the newest hearing aids are, we need real education that includes tests that show us our weaknesses. We should survey patients to get real-world feedback. We also need Internet-based, home-study programs to help us eliminate deficiencies.

I recently received a large, expensive-looking marketing piece from a hearing aid manufacturer that said in effect, “Do you want to make your patients happy? Use this new, quick-and-easy formula, for an accurate fit. Your patients will hear great!”

I gave it a try. I programmed the audiogram into the computer, activated first fit, selected the new option, and programmed the hearing aids for the patient. He could hear nothing through the hearing aids. He said, “They are not working.

In fact, the hearing aids were working, but they were very weak. They provided a little gain in the lows, but lots in the highs where this man was completely deaf. I didn't know whether to laugh or cry. Someone had paid a lot of money to develop a new fitting formula, someone else created a beautiful marketing piece applauding its merits. Yet, the first time I tried to use it, it crashed.

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Last month, I wrote about a commercial airplane that crashed because the engineer, feeling intimidated by an aggressive pilot, didn't tell him that the plane was low on fuel until it was too late to reach a safe landing place. I hope none of you are ever intimidated by the fitting software manufacturers provide. Remember, a software engineer creates this software, but the person responsible for helping the patient hear is you.

There are many reasons why unhappy hearing aid owners put them in the drawer, and we cannot control all them. However, we can at least make sure the hearing aids work. To ensure that amplified sound is set to a comfortable listening level, we can keep asking patients, “Do you want me to turn the level up or down?” until the patient responds, “This level is okay.”

Custom hearing aids are often built with fundamental flaws. For example, I just received a pair of ITEs ordered for a patient with a mild to moderate hearing loss. They arrived with tiny vents, not the moderately large SAV vents I ordered.

We order custom products using an in-office scanner, but sometimes the software selection doesn't let us order what we want. For example, I often order short canals for new users with mild-to-moderate hearing loss. However, the software doesn't have this option so we have to request it in the “comments” section.

We need to be very cautious when we use the programming software provided by manufacturers. And we need to take the time to become well trained on all the menu items on new software. The first fit software is only a suggestion. Sometimes it works wonderfully! Sometimes it works horribly!

If you have any suggestions of your own how to reduce the error rate in hearing care, e-mail them to David Kirkwood, the editor, at We value your ideas.

© 2010 Lippincott Williams & Wilkins, Inc.