I was walking through Boston Common this morning and saw a woman with a homemade sign that said something about patient safety. I stopped her and asked about her sign. She reminded me that today, July 25, is the observance of National Patient Safety Day.
Duh. I always lose track of the specific day. She could tell my recognition of what she was talking about and she asked if I worked in medicine (out of curiosity, I could tell, not because she wanted to slap me). I told her, yes, that I worked with hospitals on quality and process improvement and that (although it sounds cheesy) EVERY DAY is (or should be) patient safety day. She agreed.
Her father died, arguably due to a medical process error. She said he had a lab value was in the “critical” range. The report sat on a fax machine print out tray (in a doctor’s office, I presume), where it went unattended. Her father’s condition worsened during the time the report went unread and she ended up calling 911 and he soon passed away. It sounds like something that wouldn’t have been fatal if the test result had been picked up fast enough.
I expressed my deepest condolences to her.
We chatted and were in quick agreement that this an avoidable PROCESS error. It wasn’t a clinical error, where the test result was wrong. This was a case where the Value Stream wasn’t well designed. There were holes and gaps in the process.
So while every day should be Patient Safety Day, the express purpose of today is to remember and commemorate those who have been harmed or killed because of medical errors, including process errors. Our conversation today helped put that in perspective.
Becky Martins, like many other families members or loved ones of medical error victims, has thankfully channeled her energy into education and prevention, not anger and revenge. She runs a website called www.voice4patients.com/. This is similar to, and she is familiar with, the work of the Josie King Foundation, I invite you to check them out as well.
We were also in agreement that the path to improvement is NOT blame and punishment, but rather prevention, awareness, and adherence to standardized processes that could prevent tragedies like her fathers.
Final thought — to those working in the Lean world…. Lean is NOT primarily about efficiency, speed, flow, productivity, and cost. Those are nice side effects of a focus on Safety and Quality as primary goals. This philosophy is taught at Toyota, that safety and quality come first. The same should certainly be true. If you hear someone say (as I’ve heard many times before), that “Lean is about flow and Six Sigma is about quality,” I hope you’ll correct them, respectfully, on that point.
There’s no more important mission than improving the quality of care and patient safety. That’s why I’m glad to be part of the Lean Enterprise Institute effort and the partnership with quality-minded Lean Thinkers like Dr. John Toussaint.
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