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More Education or a Better Process??

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Fatal Dose: Ohio Girl is Killed By Medical Mistake

Here is a sad story of a girl's death due to a hospital pharmacy mistake. Pharmacies oftentimes just repackage and dispense “off the shelf” drugs (such as pills), but they often mix and formulate their own drugs, things that are bought in bulk and mixed to the proper dosage or delivery instrument (a drip bag, a syringe, etc.).

This article is pretty much blaming a lack of education for the death:

“…you may be shocked to learn that the people compounding your medication need only a high school diploma to do their job.

They're called Pharmacy Technicians, and while they do go to school to learn the field, most programs are no longer than eight or nine months.”

My first response is to disagree that there is a correlation between education level and mistakes. Highly educated and highly trained physicians and nurses are involved in errors all of the time. When we have errors, we have to look for systemic causes rather than just assigning blame. Blaming lack of education sort of implies that someone was too stupid or not educated enough, probably not the right root cause in most cases.

From the case:

Emily's chemotherapy drug was supposed be mixed in a standard bag of saline that has less than one percent of sodium chloride.

For some unknown reason, the Pharmacy Technician mixed the drug with a 23 percent concentration of sodium chloride.

Her work was supposed to be reviewed by the Pharmacist but apparently that didn't happen and the fatal dose was delivered to Emily's room.

I'm inclined to think it's also NOT a case of the pharmacy techs “not being careful.” Sure, “being careful” is one component of quality. But I've also seen many hospital pharmacies that were disorganized and had bad processes. Most pharmacies rely heavily on inspection (by pharmacists) to ensure quality. This hospital had a process in place that wasn't followed. The “standard work” wasn't being managed properly and something fell through the cracks of a badly designed system. Why not set up the process so things can be done right the first time? This shows how inspection isn't effective for ensuring quality. If you're inspecting something 1000 times and an error is never made, you might tend to slack off and assume everything is perfect. Then, an error is made and it wasn't caught because someone assumed quality would continue to be perfect.

I've seen pharmacy techs making up large batches of drugs and then labeling all of the syringes in a batch after the fact. Different pharmacy techs were making different drug batches at the same table and they were pilling the unlabeled syringes into tubs. I observed (and pointed out) that this batching and lack of process control could easily lead to an error of Tech A accidentally grabbed a syringe that Tech B was making and labeled Drug B as Drug A. If this happened, is the fault of someone “not being careful” or was it a systemic error that was just waiting to happen? An error that could have been foreseen and “error proofed?”

Increasing the education level of pharmacy techs, without improving the processes they work in, might likely do very little to improve quality.

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Mark Graban is an internationally-recognized consultant, author, and speaker who has worked in healthcare, manufacturing, and startups. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent book is an anthology titled Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus.

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