Poor hospital processes may have killed man


    MercuryNews.com | 11/02/2005 | Medical mistake may have killed man

    It is really sad when errors like this occur, it happens far too often in our hospitals. The newspaper headline used the non-blaming “medical mistake”, while I would prefer to say “poor hospital processes” were mostly likely the cause. At least the headline didn't use the blaming wording of “Sloppy nurse may have killed man.”

    Applying error proofing techniques and FMEA type approaches are critical in medicine. Sure, we can be reactive and put procedures in place after the fact (or send out more warnings that say “don't mix up these two drugs”.) Warnings HAD been sent out, particulary about these two drugs. We need to think, “What is the NEXT mistake that could occur, without better processes.” Telling people to “be more careful” won't do it. As Toyota people often remind you, people are human (even doctors!), and make inadvertant errors. We all need to work to make it harder to make mistakes.

    Yet, still, a mistake was made. We need to error proof drug dispensing, whether it is through the use of bar codes, or through better processes. Simple tools, like checklists, can be helpful in factories, hospital rooms, or airplane cockpits. Having standard work, along with some proactive problem solving, can save lives.

    As this article discusses, we have a long way to go towards perfection in health care.

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    Mark Graban
    Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


    1. It’s interesting that our hospitals here in Windsor, Ontario are now adopting lean as well. They have seen a huge reduction in wait time in Emergency Room waits due to this and they’ve just begun to look at this.


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