When I started blogging here in 2005, I was still about six months away from my transition from “lean manufacturing” to “lean healthcare.” It was mind boggling and disturbing to me to learn about the healthcare quality and patient safety crisis (something I had been oblivious to being healthy and not having a family member harmed by our health system).
I used to blog about medical errors in the news with some gusto. I am still just as passionate about working with health systems to FIX this problem, but I’m often a bit worn out on blogging about it. It’s the same stories in the news over and over… preventable errors, bad processes, staff claiming to be understaffed and overworked (and probably being right). It’s often the exact same failure modes – pathology specimens mixed up, emergency room patients dying in the waiting room, and instruments not being cleaned properly.
There are a lot of people working on healthcare quality improvement… but we still have far too many occurrences and the estimates for the number of patients being harmed goes UP over time (granted this is a very hard thing to measure).
Here are a few stories that caught my eye recently…
This isn’t the first story of a patient dying in a hospital waiting room. There was a case in Dallas (death after 19 hours) a few years ago, one in Winnipeg (death after 34 hours), and possibly one in your town.
From the story:
The worker pinned blame on hospital understaffing.
“He died because (there’s) not enough staff to take care of the number of patients we see each day,” the employee added. “We need more staff at Saint Barnabas.”
There’s always two sides to the understaffing issue. It could truly be a case of understaffing… the real problem statement is probably “having more work than can be done by the people who are working” (and there could be a shortage of physical resources).
This mismatch in workload and staffing can be solved in a few ways:
- Add people (which might not actually help if we don’t fix the way work is done)
- Reduce waste (improving processes so that the existing staff can do more patient care work… by reducing the amount of time staff spend dealing with fire fighting and other chaoes)
The man, John Verrier, was seen initially and was sent to the waiting area.
Hospital officials insisted Verrier, who had struggled with drug addiction, was checked numerous times.
But the hospital employee, who spoke on the condition of anonymity, suggested otherwise.
“There’s no policy in place to check the waiting room to see if people waiting to be seen are still there or still alive,” said the ER worker.
There’s no policy… and maybe no people with the time available to go check the waiting room to see if his condition had deteriorated in the many hours since his original triaging. This article says that the ER staff supposedly called for Verrier multiple times. But, can you blame him for not hearing them? It seems to me that it’s the hospital’s responsibility to GO FIND the person (as long as they are still there). It’s their responsibility to keep waiting times down and, if the waiting room is chaotic, have systems or technology (like restaurant pagers) that make it easy for people to be called and found.
Was this just one really bad day in the ER or does Saint Barnabas have longer-than-average waiting times? New York state ranks 46th in the country in ER waiting times. In this data set, Saint Barnabas had the worst waiting times in NYC, with an average length of stay for discharged patients of over 300 minutes (five hours). This is pretty poor performance. They don’t have data for “door to doc” in the data set – I wonder if they are even measuring that?
As we see in these cases… the problem is not the individuals, it’s the system. Bad processes, not bad people. It’s really easy for members of the public to blame the people working in the Saint Barnabas emergency department, but I bet they’re doing the best they can given the conditions they work in. Plus, we know that patient flow is systemic with the system extending beyond the ER If there aren’t enough inpatient beds, that clogs up the ER. If there aren’t enough long-term care beds in the community, that clogs up inpatient beds, which clogs up… well you get the point. Bad systems, not bad people.
Hospitals are supposed to use two patient identifiers to make sure they don’t get the wrong patient with the same or similar name… name and birthdate, for example.
A father had a camera wrongly inserted into his backside after [England] NHS doctors mistook him for his son.
The error happened after the man thought a letter addressed to his son – with whom he shares a name – inviting him for the procedure was actually for himself.
It seems that the hospital should have checked and realized that the guy who showed up didn’t have the correct birthdate. It’s probably not as bad as getting surgery as the wrong person… but there are still risks to a colonoscopy.
Note how the headline blames “bungling medics” (there’s almost a pun there), but we don’t know the circumstances. Was the department overworked and overburdened? Why weren’t leaders making sure that patient identity checks weren’t happening (assuming that this wasn’t the only time the checks weren’t done… but this was possibly the first time somebody was harmed as a result).
The article talks about other so-called “never event” mixups:
In another serious incident two prostate samples were mixed up [like these cases], resulting in one patient having a healthy prostate removed, while another was told they didn’t have cancer and only learned of the mistake later.
An error during an appendix operation led to one woman having her fallopian tube removed, while another patient had the wrong toe cut off during surgery.
I say “so-called never events” because, sure they SHOULD never happen, but they DO happen far too often.
Problems like this happen in the U.S., England, Canada, and other first world countries. Australia has done a lot of good “Lean healthcare” work supposedly, but it’s easy to be in denial that medical errors are a big problem.
It’s disappointing to hear about problems at this children’s hospital that I’ve visited multiple times… to see the outstanding Lean work they’ve done. But, clearly, things aren’t perfect yet.
A breakdown in training left instruments dirty and opened the doors to dangerous infections for more than 100 patients at Seattle Children’s Hospital.
In November, a technician discovered a poorly cleaned colonoscope. Another turned up a few days later.
“At that point in time we stopped all colonoscopies and performed an investigation and identified that we had a lapse in our cleaning processes,” said Dr. Danielle Zerr, the medical director of infectious disease at Children’s.
The scope’s manufacturer spells out multi-step cleaning instructions to avoid cross-contaminating patients. Zerr says hospital procedures came up short on those requirements.
“We feel that we didn’t have good systems in place to ensure training of new technicians who were coming into our system,” she said.
The hospital says it’s made changes. Children’s had the manufacturer re-inspect the equipment and re-evaluate hospital procedures. They also retrained 20 staffers who handle the scope, put the cleaning protocol to an audit, and reached out to public health officials for assistance.
“Re-training” is very often used as a “corrective action.” It’s not the technicians fault that they weren’t trained properly.
Why weren’t they trained properly? What is Seattle Children’s Hospital doing to see if there are training deficiencies in OTHER departments? How can they prevent training problems in the future? Are senior leaders being trained about the importance of good training systems?
The VA had problems with contaminated colonoscopy gear. More broadly, 3 in 20 pieces of colonoscopy equipment isn’t fully clean, a study shows. These are widespread problems… which doesn’t make them OK.
Cruise Ships or Hospitals
It’s not just these three hospitals that problems. Sunday, I saw a doctor from Vanderbilt on CNN talking about the 300 passengers who got sick on a cruise ship. The doctor said that some of his colleagues say that “cruise ships are more attentive to hygiene than hospitals” in their attempts to stop the spread of illness. What a sad indictment of the (still) current state of healthcare quality.
The cruise ship outbreaks are a large number of people in one place… it’s hard to hide this from the media. Healthcare infections and harm happens one at a time… and it easily hidden from the public.
It’s not bad people, it’s bad systems. And, as Paul O’Neill says, a “lack of leadership.”
As John Shook talked about in the video I shared yesterday… what is the problem we are trying to solve? In healthcare, the problem is not just cost… it’s quality and safety. Are your hospital Lean efforts focused on quality and safety?
About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as the new Executive Guide to Healthcare Kaizen. Mark is also the VP of Innovation and Improvement Services for KaiNexus.