Nursing Shortage Easing?

Slowdown's Side Effect: More Nurses - WSJ.com:

Not a Lean article, but a major issue for hospitals is a shortage of nurses. With the economy in its current condition, more nurses are returning to work. There's still a need for the reduction of wasted motion and wasted time in a nurse's workday... that's the Lean concept.

"Hospitals have also taken steps to keep older nurses in the work force by making their jobs easier, including replacing hand cranks used to lift beds with automated lift devices, bringing in lift teams so nurses don't strain themselves picking up patients, or putting supplies closer to patients' rooms to cut down on walking."

These are good practices, regardless of age. Lift assists are better ergonomically for nurses (preventing injury) and they can also help prevent patient falls. Reducing walking is good since that wasted time can be used in more productive ways (such as patient care).

Keeping supplies closer to rooms -- that goes against a previous trend toward centralized inventory cabinets (often automated) in a floor or unit. The advantages were all for materials management -- it was easier to restock and kept better control of inventory. But, optimizing materials management shouldn't be the primary goal. The nurses are providing "value added" care -- the job of the rest of the organization should be to support them in "making their jobs easier." There's a pretty direct parallel to a factory using material handlers to allow assembly operators to be more efficient.

You don't want assembly workers to stop, looking for parts. You don't want surgeons digging and searching for tools during a procedure (nurses or techs hand the instruments to the surgeon, an old idea that originally came from Frank Gilbreth). You also don't want nurses to be roaming around, searching for medications or supplies either. Systems and processes (and technology) need to support them in the way they do their jobs.

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The Power of Asking "Why?"

reportonbusiness.com: Asking 'why' again and again is harder than you think, but it works

It's kind of neat to see a column about the "5 whys" method in a general business publication (link above). The consultant and professor in the article gives proper credit to Toyota and Taiichi Ohno, but curiously calls it the "Japanese Manufacturing Technique" (as if that's a proper name). I've near heard that phrase... something he coined rather than just "Lean Manufacturing" or the "Toyota Production System?"

Anyway, the article gives a good example of a 5 Whys analysis from Ohno. In my experience, 5 Whys is hardly ever that neat and tidy (you can hit some dead ends or have multiple branches in the answers), but you can get some real breakthroughs.

Going through a 5 Whys exercise with a hospital group once, we asked "Why are hand hygiene practices not followed 100% of the time?" One real breakthrough was a comment "Our hands and arms are full when leaving a patient room sometimes." We asked why that was, and kept asking why -- turns out that carts were not always available, so the follow up would be a 5S initiative around proper storage locations for carts and having the discipline to keep them there. Instead of browbeating nurses for not washing, our job was to make it easier for them to do the right thing. We thought that was good problem solving -- or more effective than hanging more signs at least.

The linked article also talks about some of the downsides of asking why, especially if you're challenging technical experts or "lords," as he calls them. People can get defensive. You really have to watch your tone of voice when asking why. I've found it's better to ask "Why is it that...." instead of "Why do YOU..." because people take the latter as direct criticism.

Asking "why?" in private or 1x1 can also be less embarrassing than asking someone in front of a group. You always have to be aware of politics and sensitivity. Most of us aren't an Ohno, being comfortable yelling or screaming at someone.

What are your experiences with the 5 Whys, good or bad?

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The Waste of Handwritten Notes

Nurse + Blog = PixelRN: 16% of the US economy runs on scrawly, handwritten notes.

PixelRN is a blog written by a nurse (who is unfortunately considering leaving the field). She writes about the problems involved with handwritten orders, charts, and notes that are used in so many hospitals. This is particularly a problem in hospitals without "electronic medical records" (computer systems that can be helpful, but they're also not the cure-all that vendors would claim -- more on that later in this post).

Charting and records -- that's an example of how quality and efficiency go together. EMR can be faster (but not always) and it can also help prevent errors or miscommunications. PixelRN writes:

I made a mistake yesterday. I didn’t just miss one order. I missed A WHOLE PAGE OF ORDERS.

Why? Because the doctor wrote them on a separate page and stuffed them into the side pocket of the binder, rather than putting them in the proper place.

Here's a process error that could really impact that patient's care. Part way to a root cause, we could ask "why didn't the MD put the orders in the right place?" The RN probably just gets blamed for not finding them (and blamed for not reading the MD's mind). If we put an electronic system in, we still have to rely on people using it properly (assuming they're trained and they understand the implications of not following the standardized work). PixelRN again:

Fortunately no one was harmed, although the patient did have to stay in the recovery room for an additional hour because I didn’t see the order.

This was my mistake and believe me, I owned up to it. I apologized to the patient for creating this delay and I apologized to the attending for missing his order, but I know that this mistake could have been avoided if the recovery room used a computerized ordering system.

Or if the MD had properly utilized the paper chart binder. Why is the RN apologizing?

She writes further:

And yet there is such a lack of standardization in the way that doctors write their orders, so it can be difficult to carry them out. Do the recovery room nurses care about this? The answer appears to be no. Whenever I ask the nurses about this situation their reply is this, “Oh we’ve been fighting this battle for years. Nothing ever changes.”

How do you get beyond that kind of apathy?

It requires Leadership! This isn't something that Lean can solve if there's not leadership and a drive to fix problems like this. It's so sad to hear about the frustration (and to see it first hand)

I've seen cases where a hospital HAD the electronic systems and they were used inconsistently. Some MD's refuse to use the Computerized Physician Order Entry Systems (CPOE). The electronic charting systems are often slow and glitchy, leading nurses to workaround the problem by writing down and carrying lots of paper notes around. So what was really solved?

I'd argue that hospitals need to focus on "process" as much as (if not more than) technology. Don't expect technology to be a cure-all, because it's not.

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A Lean Nursing Example in New Zealand

Hospital's shake-up gives nurses more time

Here's a nice news article about the use of Lean in a hospital in New Zealand (hat tip to Michael for sending it to me).

Middlemore Hospital is the first in the country to implement the "Releasing Time to Care" scheme, which works with nurses to improve the efficiency of their daily duties.

That's a great title for a program. Although they clearly state they are implementing Lean concepts, the primary goal is never "implementing Lean" - the goal is better patient care and this is often done by reducing waste for the nurses and staff, allowing them to spend more time on patient care.

Middlemore gets it -- they aren't using Lean to drive layoffs:

Despite the amount of time freed up for nurses, no redundancies would follow, general manager for quality improvement Allan Cumming said.

There are so many good anecdotes and examples in the article, I won't try quoting them all -- check out the article. This one point jumped out at me though:

Mr Cumming said nurses generally spent about 33 per cent of their time with patients. That figure was expected to double as the scheme was introduced.

That 33% number jumps out since I also saw that number cited in an article about Virginia Mason Medical Center in Seattle - their nurses were also only spending about 30-33% of their time with patients. I've also observed and calculated that exact same number when I've worked with nurses in an inpatient unit.

The remainder of that time is spent on some activities that are "value adding" without the direct patient contact (such as charting) and a lot of activity that is clearly non-value-added, such as searching for missing medications (medications that shouldn't be missing if a better process were in place).

From Middlemore:

* A ward which used to have only two thermometers to share between nurses has switched to disposable thermometers. They cost less and can be stored at each bedside, saving a substantial amount of time each day.

* Storage areas have been cleaned out and reorganised to the nurses' specifications, meaning a search for supplies takes seconds, not minutes

This is really encouraging. I hope we start seeing more examples of Lean concepts helping nurses and helping patients.

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The Life of a Nurse: Waste and Workarounds

Care and Chaos on the Night Nursing Shift - WSJ.com

Free Version via CareerJournal.com

The linked article is a virtual "gemba walk" for those of you who have asked how and why Lean is helpful and necessary in a hospital environment.

When you read the description of a nurse's day and activity, you'll notice waste and workarounds galore.

With Lean, the focus in hospitals is reducing non-value-added activity and waste so that nurses and other caregivers can spend more time with patients, providing care and treatment. Not being able to find needed supplies -- that takes nurses away from patients, delaying care and causing frustration. Missing medications, missing physician orders all create distractions, rework, and delays.

I've spent just a little time in the nursing gemba. I couldn't imagine doing their job for a 12-hour shift... if you think factory work is grueling, follow a nurse around for 12 hours. It's quite an eye opener.

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The Need for Lean at BIDMC

I read Paul Levy's blog every chance I get. He is the CEO of Beth Israel Deaconess Medical Center in Boston. Although fellow blogger Kevin Meyer and I caused a bit of a kerfuffle with him, unfortunately, earlier this year (link here), I hope we have all moved beyond that. I respect his efforts to drive improvement at a hospital (with Lean and other methods) and I respect his openness with the public on quality data and his thoughts on Running a Hospital.

In two recent posts, he gives some great, very real insight into the types of problems that hospitals face today. This is my attempt to empathize, not criticize. These are all very widespread issues that most hospitals face (except for the skyrocketing Boston salaries, but that's a problem to some extent in smaller towns with competitive hospitals).

First is an outstanding post where he shared a letter he wrote to BIDMC employees. He started the letter (bold emphasis is mine):

What's the most important activity at our hospital? Providing patient-centered care?

Right!

But what do we spend most of our time doing? Patient care??

Wrong. It is fetching. As in spending time trying to find a piece of equipment, a certain paper form, or some other supply. Or it’s re-doing work. As in writing the same piece of information in 3 different places.

Admit it. If you are a nurse on the floor or the OR or the PACU, a respiratory therapist in the ICU, a person cleaning surgical instruments in CPD, or a practice assistant in a clinic, think of how much time you spend fetching instead of actually taking care of a patient or doing the job you’ve been hired to do to support patient care – whether that’s running lab tests, preparing food in our kitchen, or repairing a broken piece of equipment. How much of your day is spent in these ways versus face-to-face time with patients or in doing something tied directly to patient care and the support of that care? If you are a typical person here, it is way over 50% and more like 80%.

But I don't have to tell you that, do I?

Paul is pointing out what we would all recognize as "waste" in the Lean terminology. Employees are interrupted and distracted away from their true "value adding" work -- caring for patients or supporting those who do directly care for them. The problems are by no means unique to BIDMC. Every hospital I've seen has these same problems, even if they are already working on Lean. The good news is that Lean methods help reduce exactly the waste that Paul describes, but you can't fix everything everywhere all at once. I hope they are making progress with their Lean efforts.

He continues to nail it right on the head:

Every day, thousands of you undertake "work-arounds" to solve the problems you face in delivering care. And you do solve those problems -- by dint of personal commitment, hard work, and good will. As a result, our patients get extraordinary care.

But, because we all invent work-arounds, we often don’t solve the underlying work process problems that pervade every aspect of what we do. And you go home feeling really tired and
wondering how you really spent your day.

Intermission for a shameless plug -- these are exactly the concepts I'm writing about in my upcoming book on Lean Hospitals (not finished yet and not out until mid 2008).

Paul then starts writing about solutions... I wish he had mentioned Lean. I know nothing about the consulting approach he writes about, but an employee centered approach, making sure they feel pride in their work and appreciated sounds all right to me. But Lean will help too. I know I tend to be a bit of a one trick pony, but there's room for other complementary approaches.

So the hospital is full of waste and rework in their processes. Employees feel overworked and under appreciated. What does Paul describe in his next post? How they're hiring like crazy and how labor costs are skyrocketing.

In his theme of openness, Paul shares their staffing levels over the past few years:

Here is a summary of the average FTEs (full-time equivalents) on staff year by year.

FY2002 -- 4,562
FY2003 -- 4,694
FY2004 -- 5,013
FY2005 -- 5,353
FY2006 -- 5,635
FY2007 -- 5,792

For fiscal year 2008, we are budgeting another increase, this one in the range of 10%. Part of this is due to further expansion of staff -- almost 450 new positions. Most of these are related to increased patient activity on our floors, clinics, and in the ORs. A significant number, too, are being added to enhance customer service and to meet safety and regulatory requirements.

Imagine the opportunity that comes from reducing waste with Lean. Some freed up time from existing employees would go toward more value adding time, so, for example, a Lean hospital might not change patient/staffing ratios. But patients and employees would be happier all around. It's hard to get your nurse to respond quickly when he or she is down the hall rummaging for supplies.

(On a somewhat parenthetical note, Lean factories do a much better job of using material handlers to keep assembly line workers productive and focused on value added work. Seems like this is a concept that hospitals would be anxious to adopt. I've seen basically that approach work very well in a hospital lab, eliminating the need for value adding Med Techs to walk and get their own supplies -- that's material handling, not what they went to school for).

But, in other jobs, especially in support or ancillary areas, eliminating waste and Non Value Added time means that employees can do MORE value added work (more lab tests, more medications, more sterilized instruments). That's the kind of productivity improvement that helps you increase volume without increasing headcount.

I wonder what productivity increases the hospital is seeing through their existing Lean efforts? I wonder what industry wide productivity increases would do for the serious shortages of key technical staff, including nurses, medical technologists, and pharmacists?

Keep at it everyone. Good luck with your Lean efforts.

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Updated: How Often Must the Same Mistake Be Repeated?

Dennis Quaid's newborns reportedly harmed by medical mix-up - Los Angeles Times

(Updated 4:57 PM, again at 9:51 PM, see bottom of post)

If this story sounds familiar, it's because it is the exact same error as one that killed three babies in Indianapolis last year. This time, the error has harmed the twin babies of actor Dennis Quaid. The babies are reportedly in stable condition at L.A.'s Cedars-Sinai hospital and will hopefully pull through. My thoughts and prayers go out to the Quaid family.

"Dr. Michael L. Langberg, Cedars-Sinai's chief medical officer, confirmed in a statement late Tuesday that "as a result of a preventable error," three patients had their intravenous catheters flushed Sunday with a concentration of heparin 1,000 times higher than the normal protocol. Staff members used vials containing a concentration of 10,000 units per milliliter instead of similar vials containing a concentration of 10 units per milliliter."

This was truly a preventable error and something that should have never occurred. So what is the response? Do we ask "who did this?" or "why did this occur?" Those are two very different questions.

First off, let's give the hospital credit for their public response:

"Cedars-Sinai spokesman Elbaum said no employees had yet been disciplined because "our focus tonight is on quickly determining what needs to be done to make sure it doesn't happen again." For instance, all 1,800 nurses coming on duty beginning Tuesday night will be retrained on medication safety practices before they begin seeing patients. Other steps also will be taken."

It says "had yet been" disciplined, meaning I guess they are leaving that door open. Focusing on why it happened and making sure it doesn't happen again are good problem solving responses. With Lean, we first want to ask "why did this happen?" instead of "who screwed up?" The chief medical officer was quoted on the news as saying it was a "preventable error" but he also said that procedures and standards were not followed. That sounds like a precursor to throwing someone under the bus for not being careful.

In the Lean approach, management has a responsibility to ensure that "Standardized Work" is being followed. If the standardized work (or procedures) say that nurses are supposed to double-check the labels, how often does management spot check that the right process is being followed? A Toyota plant does not just assume that the work is being done properly, the managers and supervisors are constantly auditing and checking that procedures are being followed. They are not waiting for a defect or customer injury to occur first.

Blaming an individual might feel good, but who do we blame? The nurse who administered the wrong dose? In the Indianapolis case, the nurse never expected that an adult dose of heparin would be in a neonatal I.C.U. Do we blame the pharmacy technician who likely delivered the wrong dose to the unit? Do we blame the pharmacist who was supposed to confirm the medications that were being delivered? Do we blame the person who possibly put the wrong vial into to the wrong bin in the pharmacy? If the pharmacy technician scanned a bar code on the bin (and assumed that the medication also matched), do we blame them? Or do we blame the purchasing agent who buys different dose vials that look similar? Or do we blame the manufacturer of the heparin?

People were blamed in Indianapolis. But that didn't prevent the problem from happening in L.A.?

Cedars-Sinai is now taking reactive measures to train and raise awareness. Why was that not happening already? Does every single hospital have to make the same mistake before they take preventative measures? How about being proactive? How about we not rely on asking people to "be careful?"

In Indianapolis, they have "double checks" which is like a "double be careful."

"Nurses at Methodist didn't check the label and administered the wrong dosage. After the incident, the hospital required a minimum of two nurses to verify any dose of blood thinner used in the newborn and pediatric critical-care units, among other steps."

That's just another form of inspection. It doesn't prevent the root cause of the problem. We can't rely on people to be careful, especially when nurses often work 12 hour shifts. People get tired, we're human, we make errors. That's why the Lean philosophy of error proofing is so powerful. It recognizes that people make mistakes, so we design systems that make it less likely for errors to occur. And don't call it "dummy proofing." The nurses who make these mistakes aren't dummies. This might have been the only mistake they've made -- they were careful every other time, but here was one mixup that can have fatal consequences.

A professor of pharmacy in San Francisco was quoted as saying:

"This is not an unheard-of error," Kayser said.

It sure is. The FDA and Baxter issued a warning in February 2007. And we're going to keep hearing about it until every hospital takes proactive and preventative measures to keep this from happening. Reacting after an incident shouldn't be looked upon favorably.

Baxter's recommendation, for now, was to "be careful" basically:

Both products use blue as the primary background color on their labels, though in different shades.Baxter is looking for ways to vary the packaging to prevent future errors. In the meantime, it suggests that healthcare workers check their inventory to ensure no mix-up has occurred; notify staff of the problem; be sure not to rely solely on package color to identify a product; and always read the label and verify that the correct dose and product are being used.

Look at the packaging. Sure, they don't look identical, but imagine you're in a somewhat dark patient room at 3 a.m. Why isn't the stronger dose in a larger form factor bottle?? Or a different shape? Or maybe the adult dose bottle can have sharp jagged edges to poke the nurse to make sure they are being careful? We need error proofing devices, not "being careful."

If I ever have children, and they're in a hospital, I'm going to be a nervous wreck. My advice to others would be to have someone monitoring your child and their care 24 hours a day. You can't trust the system to protect them for you, unfortunately.

There is a surprisingly intelligent and informed comment on the E! Online website, discussing this problem (scroll down to the 4:27 comment). The comment actually comes from this blog posting, written by a nurse. Surprisingly, she primarily blames the nurses!

Yes, nurses in this day and age are very rushed to get everything done for their patients, and there is definitely not enough time in the day to get it all done. Nurses are overworked, underpaid, and stressed to the max. We are assigned to too many patients at times, creating unsafe situations for the very people we are here to help. But by skipping the very foundations of safety, we are putting each and every one of our patients at risk for medication errors, injury and potential death."

Can you really hold people solely accountable when they are overworked, stressed, or tired? I'm not saying people have zero responsibility, but merely blaming someone for firing a nurse won't prevent this from happening again. Training will help, at that hospital. But what about the others? I wish the media would go to the OTHER hospitals in L.A. and ask, "So what are YOU also doing to prevent this?"

Maybe this story will get the right kind of coverage since it's a celebrity's babies?

Update: This blog says the error was a result of a technician storing the drug in the wrong location.

Update: This site (lawyer alert) says that Methodist had made the same mistake five years before killing the three babies last year. The news article he links to says:

"The parents of one of the children overdosed five years ago were assured by the hospital that steps were being taken to ensure the mistake was not repeated, but those steps didn't stop it from happening again."

That's why being careful or even saying "we have procedures and policies" doesn't work. At some point, hospital leadership should be held accountable, not just individual workers.

The lawyer has it wrong when he says:

"Administering an adult dose of Heparin to an infant is the type of error that should only happen once in the history of a hospital."

No, it should never happen. Hospitals need to be proactive and NOT wait until a mistake is made. We need Lean and Toyota Production System methods to spread within health care.

Update (9:51 PM): This blogger (another lawyer!) reports that the celebrity site tmz.com is reporting:

We're told one dose was given on Sunday morning, another on Sunday evening.

We're told as many as thirteen patients at Cedars were mistakenly given the overdose of Heparin, but the effects are more critical because of the age and weight of the twins.

Wow, that is one hell of a systemic problem. It's not as simple as one nurse being careless one time if the Quaid twins were overdosed TWICE and it happened with other patients. Yikes, how is someone "not careful" that many times??

The lawyer then, predictably, goes on to rant that problems like this happen because hospitals aren't as afraid of being sued anymore, thanks to tort reform. Ah, the fear of lawsuits, the best path to quality! Not really. He also confuses the heparin dosing error with the "heparin and insulin confusion" error, which the FDA also gave a warning about and also happens all over the place.

"You're the Time Study Man"

No, that isn't me in the picture. I don't wear ties with short sleeve shirts. Too much like Sipowicz from NYPD Blue, not my style.

I have a funny story from earlier this week. I was doing some process observation with nurses at a hospital, helping them identify waste and possible Lean improvements. We entered a room and the nurse introduced me quickly to the patient. I was carrying my notepad, but no stopwatch or anything.

The elderly lady says, "So you're the Time Study man..." with a smile. I thought, wow what a wonderful antiquated term. It's the stereotype of the industrial engineer. When I changed my major to I.E., my dad's friend (an Electrical Engineer, like my dad), asked how my stopwatch training was coming along.

As this old 1950's article from Time Magazine (amazingly available online) describes, the Time Study Man wasn't exactly a friend of the workers. Time studies, in a traditional sense, were very Taylorist in nature. The educated engineer stands over the working man, timing him and thinking of ways to "speed him up" (sorry for the non-inclusive gender terms, this is the 1950's after all). It was a conflict between worker and management, with the Time Study Man caught i the middle.

Of course, the Lean approach is different. This is about partnering up with employees to identify waste. Making their job easier also helps improve service and care for the patients. In the context of a "No Layoffs Due to Lean" promise, finding improvements isn't going to lead to job losses. Instead, it frees up time to do a good job and to spend more time with patients, instead of being rushed. Lean isn't only about doing the value added work faster, it's about reducing non value added work and eliminating delays.

So, as I described briefly, with a smile, "Well, sort of... but we're working together to find ways to provide you better care." Was it awkward to have me following along? Sure, somewhat. But, management had done a very good job of explaining what this was about and what it wasn't. It's not about nurses running faster. It's about avoiding the need to walk (or run) by improving the process and eliminating all of the types of waste (which are present in the hospital workplace, to be sure).

Such things were known, even in the 1950's, as the Time article says:

"Such cooperation is the best evidence that the time study creates few problems if the company uses competent technicians who carefully and repeatedly explain what they are doing, and include in any job evaluation such human factors as fatigue and boredom. An atmosphere of good labor relations is also a big help; although the International Union of Electrical Workers refused to permit Westinghouse's time study, it raised no objection to a similar study at G.E. Where a union suspects that the time study is being used by management to cut pay or fire workers, the stopwatch will always make trouble. But properly used, the time study is a tool that can not only cut costs and hike production, but boost both workers' wages and company profits."

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Just Throw Everyone in Jail, Then

WFAA.com | Nation

It sure is easier to think that medical mistakes are as simple as one person being criminal, or negligent, or incompetent. Let's assume it's that easy to assign blame to one individual who is part of a complicated system.

MADISON, Wis. – By most accounts, nurse Julie Thao helped hundreds of women giving birth during a 15-year career. But a drug mix-up that led to a death may send her to prison, frustrating fellow caregivers.

Prosecutors filed a felony charge against Ms. Thao, igniting a debate over whether medical professionals who make unintentional yet deadly mistakes should face criminal charges, on top of civil punishment from victims and regulators.

Officials say the charge against Ms. Thao reflected a series of dangerous decisions she made that led to the July 5 death of 16-year-old Jasmine Gant, an expectant mother whose 8-pound baby boy survived.

Jasmine died after Ms. Thao mistakenly gave her a dose of epidural instead of penicillin to treat a strep infection during labor. The epidural, a potent pain reliever used during childbirth, caused Jasmine to go into cardiac arrest and die within hours.

A woman is dead. But is throwing a nurse in jail the right response? Does that help prevent any other medical mistakes? Likely not. This nurse had a perfect track record. As with many systemic errors, it's a matter of chance: wrong place/wrong time for the patient and for the caregiver.

Don't get me wrong, I'm not making excuses for people. People make mistakes. Maybe she should have been fired. But throwing her in jail doesn't seem to help anyone. What about management's responsibility for quality, for making sure processes are sound and that standard work is being followed?

"Julie did not want to make an error. She did not want to hurt a patient," he said. "There are many nurses who would say that could happen to any of us."

Of course she didn't want to make an error. That last part of the quote is haunting... it could happen to any of us.

But the seven-page criminal complaint says Ms. Thao's "actions, omissions and unapproved shortcuts ... constituted a gross breach of medical protocol."

Among them: retrieving the epidural from a locked storage unit without a doctor's order, failing to scan the medication in a computer system that would have detected the mix-up, and ignoring large warning labels on the epidural.

Ms. Thao also injected the epidural too fast in an effort to save time, hastening Jasmine's death, and failed to double-check the patient, route, dose, time and medication, the complaint says.

It's clear that the nurse made mistakes. But again, isn't it the hospital administration's job to make sure the nurse is doing things properly? The CEO isn't facing indictment. Deming said top management is responsible for quality, I'm sure that would have applied to hospitals.

How long was this nurse, and other nurses, cutting corners to get stuff done, to work around bad processes? How many times did a nurse complain about not being able to get drugs? I bet this same set of circumstances happened before -- people not following standard work -- and where was administration to notice? For each safety death, there's usually plenty of near misses that might have led to process improvement, to avoid the death. If management is looking for standard work, you can pre-empt problems BEFORE a near miss or a death (google the concept of the "safety pyramid").

Stories like this always involve an overworked or tired nurse. Where is management's responsibility to remove waste from the system or to staff properly so staffs aren't overburdened? This is the concept of "Muri" -- overburdening people should be avoided in a lean system. Muri leads to mistakes.

I've seen hospitals where the staff is chronically overburdened because nobody is (yet) looking at process improvement and reducing waste. Instead, they keep the patient:nurse ratios the same. If staffing is short, instead of reducing waste, they close beds, meaning they provide less medical care to the community.

Again, I'm not making excuses for the nurse. She screwed up. But, the system screwed up. Management screwed up. The system and management aren't going on trial. If we throw everyone who ever made a mistake in jail, we'll still have mistakes and further deaths, because we aren't always fixing the system.

What's criminal is if EVERY hospital in America doesn't review this case and the circumstances involved. Do an FMEA activity and improve your process to make sure this exact same error and death doesn't occur in YOUR hospital. Otherwise, you'll have to count on being lucky. It could happen to anyone.

Lack of Error Proofing Kills 3 Babies

This is an incredibly sad, and completely preventable, situation. Three babies are dead, and three more injured, because the wrong drug was administered to them at an Indianapolis hospital.

Let's keep in mind, first, this quote from the World Health Organization:

“Human error is inevitable. We can never eliminate it. We can eliminate problems in the system that make it more likely to happen.”

This quote could easily come from Toyota leadership. This is why they error proof. You want to prevent good people from making mistakes. My point is to look at this situation by NOT pointing fingers of blame at an individual.

The situation and the news stories:

Initial story about the first two deaths from a local news station

CBN story, again after the first two deaths

"At the newborn intensive care unit of Methodist Hospital, the staff is blaming the newborn deaths on human error. Somehow the wrong dose of a blood-thinner medication, Heparin, was stocked in a hospital drug cabinet.

President and CEO of Methodist Hospital, Sam Odle, said, "They're both one-milliliter vials. One has 10,000 units of heparin, one has 10 units of heparin...so the nurses -- knowing they only carry one dose on the unit -- took the vial out and administered it to the patients."The mistake proved deadly.In all, six premature babies were given adult doses of the drug. Three babies are in stable condition. Another is in critical condition. Two babies died."

A lot of the initial response was focused on "a nurse made a mistake." Situations like this are far more systemic and wide spread than to think a single person and a single mistake led to this.

A nurse said:

"I have always been confident that the drug that I'm looking at is the drug that's in the drawer," said a nurse. "But, of course, it's still my responsibility to assure it's the right drug."

Since this was a CHILDREN's ICU, you would wonder why an adult-dose drug was ever there. The nurse is saying that it should NOT have been there. But still, a nurse did not read the label, she ASSUMED. That's just one mistake. A better process would be to ALWAYS double-check the drug name and dosage. The drug should have been labeled "Heplock" but it was actually "Heparin" that was loaded into the cabinet. Heparin has been in the news before when adults are killed because "Heparin" was confused with "Insulin" (same vial, clear liquid, etc.).

Looking at future PREVENTION, the CBN article says:

"Under new guidelines, the hospital staff will double-check drug labels and remove certain doses of the blood-thinning drug, heparin, from their unit."

Now the second part sounds like an error-proofing step.... but removing the drug that already shouldn't have been there is very reactive. How do you prevent the adult-dose drug from getting there? What process was responsible for that?

The Washington Post news story, after the third death has some more details:

"According to hospital officials' account, a pharmacy technician had loaded the cabinet with heparin, at 10,000 units per milliliter, instead of hep-lock, at 10 units per milliliter."

So we had one mistake, a tech from a different department loading the wrong drug. The nurses, far too trusting of the system, didn't double check the label and assumed, incorrectly, that they have the wrong drug -- partially lulled to sleep by the technology that you might expect to prevent this. There is a cabinet in the ICU that requires a nurse to enter their ID code and a patient code -- it prevents the wrong DRAWER from being opened. But, it doesn't address the issue of a pharmacy tech loading the wrong drug. How is that error-proofed?

Everyone is pointing fingers, some of it system related (how does the drug maker help make the packages more distinct, so Heparin and Heplock aren't confused?)

The mother, and we can't possibly have enough sympathy and empathy for her pain and suffering, she says:

"The nurses is what I'm blaming. They need to lose their licenses is what I am saying so it won't happen again to the other babies," Jeffers said.

I'm sorry, but that's not going to prevent other deaths. Everybody in the system, particularly the nurses, were probably trying their best. We need to improve the SYSTEM to prevent it from happening at Methodist and at other hospitals. Was this a one-time error?

"Methodist has acknowledged two other heparin mix-ups involving babies in 2001, and said both infants recovered."If this was an isolated incident I would say that it would be solely the responsibility of the person at the hospital," Lee said. "But this is not an isolated incident.""

The five nurses and pharmacy technician involved are on leave and receiving support and counseling, and are expected to return to work, Odle said.

I'm sure all of the hospital employees feel sick over what happened. I know I would. Hell, I read about this yesterday and I had basically a nightmare where I was working with a pharmacy and trying to get them to improve, mistakes were still being made and I was yelling at people (and I'm not normally a yeller). This kind of situation really bothers me and reinforces my mission to work in lean healthcare.

When I'm back to work at my client tomorrow, I'm going to talk with a pharmacy tech I know and get her perspectives on this, what procedures would be in place at their hospital to prevent this kind of situation.

People need to "be careful" but that isn't enough. As the quote up top says, people are human. Blaming "human error," as the hospital did doesn't mean "what individual screwed up?" It means, humans designed a fallible system. We need to try harder to design error-proofed systems, whether in healthcare, aviation, etc. In the current situation,d either in it takes MULTIPLE errors for a death to occur, but it still happens too often.

There are over 5,000 hospitals in the U.S. This kind of error could happen (and probably does) at any of them. My question is this --- what kind of network is in place to share situations like this? EVERY hospital in America (and the world) should be looking at their own processes today to prevent THIS problem. With the internet and modern communications, each hospital shouldn't be operating in a vacuum. One mistake ANYWHERE should be enough to drive change and process improvement EVERYWHERE. We don't need to make the mistake at each hospital before each hospital fixes the process.

Do we have any Intel readers who could share how "Copy Exact" communication among the fabs takes place? Sure, a network of 5,000 hospitals under different ownership is one thing compared to a smaller number of fabs all run by one company, but I'm sure lessons can be learned.

One lesson for me -- if I had a baby in the ICU (or any loved one in the hospital), I would be there and would monitor each and every drug that was ever administered. If a nurse is offended, so be it.