NHS: 60,000 medication blunders in 18 months – Health News, Health & Wellbeing – The Independent

Trust me, I’m not picking on the NHS. There’s a lot of good things happening here with Lean and I’ll blog about some of that soon.This article from the Sunday Independent highlights some numbers on medical errors:

Medication blunders by NHS staff are killing patients at a rate of two a month and costing the health service £775m a year, a watchdog has revealed.

The National Patient Safety Agency (NPSA) has found that thousands of patients are being given the wrong drugs, too little or too much of their prescribed medication or miss doses altogether.

The study found 60,000 “medication incidents” were reported by hospitals, GPs, pharmacists and community health centres over 18 months up to June 2006. Thirty-eight patients died as a result of these mistakes and a further 54 were dangerously harmed.Experts believe that fewer than one in 10 cases are reported, suggesting that there may have been as many as 708 deaths out of one million incidents.

When you look at patient safety or medical error problems across the United States, Canada, and the U.K., they’re roughly the same on a per-capita basis. It’s not like any country is an order of magnitude better or worse than others. The operational processes tend to be the same across countries, leading to similar results, regardless of the payer system involved.

The response to these errors? We need more “Lean thinking” than what’s demonstrated in the following quote:

These findings come a week after the NPSA Rapid Response Report which urged “extra care” when administering powerful drugs such as morphine, amid concerns incorrect dosing had caused several deaths since 2005.

As I’ve blogged about before (and write about in my book), “being careful” is not enough. Being careful is a good start, but bad processes and bad systems can defeat even the most careful of individuals. Urging staff members to be more careful, in my view, is unlikely to do much long-term good. Firing employees after the fact of an error doesn’t do anything to improve the underlying processes.

If a process was error-prone, someone else is likely to make that same error again. If you could proactively identify which employees or physicians are likely to not be careful, those who going to cause an error, then just proactively fire those people. Problem solved right? Not really. We don’t have that ability, so we’d better focus on processes and systems… not just “being careful.”

The Lean approach urges us to create “error proofed” processes. Toyota and Lexus don’t have better quality because their people are “more careful.” It’s all about systems and processes.

About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology, focused on improving quality and patient safety, improving access, reducing costs, and fully engaging healthcare professionals. He is also the Chief Improvement Officer for KaiNexus.

Tagged as: Canada, England, Error Proofing, Patient Safety