Long-time readers of this blog (and my own) know that I focus on bringing lean techniques to individual work habits. One topic I often cover is how interruptions — from email, phone calls, colleagues — creates inefficiency and waste for office workers. I suspect that readers sometimes think that this is a pretty minor issue — that “real lean” addresses more significant things, like defective parts coming out of a grinding shop.
Now comes a report from the University of California at San Francisco that interruptions aren’t just minor annoyances that make people a little less efficient. They cost money and lives.
A study involving nine San Francisco Bay Area hospitals focused on improving accuracy in administering drugs – with particular emphasis on reducing interruptions that often lead to mistakes – resulted in a nearly 88 percent drop in errors over 36 months at those hospitals.
“Medication errors make up the largest slice of the medical error pie,” said Julie Kliger, director of UCSF’s Integrated Nurse Leadership Program, which developed the medication errors program. “Improving these numbers is a huge benefit to patient safety and, secondarily, it reduces costs.”
Lest you think this is just a minor issue, the Institute of Medicine estimates that errors in administering medication cause about 400,000 preventable injuries in hospitals and about $3.5 billion in extra medical costs each year.
What’s most exciting about the study is the way they reduced those errors. In true lean fashion, front line workers — nurses — figured out ways to improve the current state without spending money. No fancy jargon, no value stream maps — just common sense and a desire to fix a problem.
Striving to reduce interruptions that lead to mistakes, teams of nurses at the different hospitals came up with a variety of methods – often surprisingly low tech – to alert others they were administering medications. The strategies included everything from wearing brightly colored vests or sashes to establishing “quiet zones” or making announcements at key points in the day when medications are being administered.
At San Francisco General, for example, nurses found they were constantly being interrupted in the medication room because their colleagues could see them through the windows. So they covered the windows.
The solutions “have to be low tech because we, as staff nurses, don’t have the money or ability to make high-tech changes,” said Celeste Arbis, a registered nurse in the medical-surgical unit there. “Something as simple as changing the process just a little bit can make a big difference.”
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