Are Errors Inevitable??
Huge Price Paid for Stupid, Careless Medical Error | Tortdeform
Lots of discussion of the sad case of the mixed up laboratory specimens and Darrie Eason having the unnecessary double mastectomy.
One comment (from a reader of the blog I linked to above) said:
“IN ADDITION, to put things in perspective, THERE IS NOTHING ANYONE CAN DO TO AVOID MISTAKES. Every lab, hospital, treatment center has protocols to ensure patient safety. However, there is nothing anyone one can do (Except GOD himself) to stop any lab tech from making mistakes. Training, supervision is important but ultimately, even ALBERT EINSTEIN himself, if careless, could do a mistake.”
Wow, I couldn't disagree with that statement strongly enough. Nothing we can do? That's the mindset that allows errors to happen, that they're inevitable. That's a dangerous mentality, whether it comes to hospitals, airplanes, or assembly lines. I hope quoted mentality isn't that common in the general public – or your organization. How prevalent do you think that mindset is?? Click “comments” to let us know.
It's hardly playing God, if you will, to try to prevent human error mistakes. The Lean approach and the Toyota Way recognize that humans are indeed human. We DO make errors. Hoping for the best (or praying) isn't any better of a strategy than would be telling people to “be careful.” We have momentary lapses, even the best of us.
I keep thinking back to Dr. Atul Gawande, in his book “Complications: A Surgeon's Notes on an Imperfect Science,” who made the case that he worries about the good doctors making mistakes on their bad days. The bad doctors get drummed out of the system (maybe not soon enough). But, any of us (yes, even Einstein) are capable of errors.
Using true Error Proofing methods is good for the customer (or patient, depending on the setting) and it's also good for the doctors and the hospital employees. Nobody WANTS to make a mistake. We're trying to protect them so one bad day doesn't ruin their career or their life (yet alone patients like Darrie Eason).
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You are exactly right. Error proofing is great. It is so satisfying to make a process systemically either mistake proof (in some specific way) or make it less likely for mistakes to happen.
I agree with both of you. The whole point of error proofing is to prevent mistakes. Can it completely eliminate the possibility of mistakes? Of course not. But it can certainly substantially reduce the possibility, which in this specific case, IMHO, would have eliminated the suffering of these two patients.
Error-proofing, don’t forget, also entails the 5 why’s to remove the chance of REPEAT defects. I think that is the most significant point missed by the commenter.
How many times has this happened, at least twice, if I remember Mark’s first post? If the ‘business’ of healthcare shared knowledge and ideas, AND followed Lean principles, this mistake could have been error-proofed after the first problem. That could have saved at least two other people from experiencing the same defect (I don’t mean to generalize the ‘defect’ – no disrespect).
That is why mediums to share ideas, across any (all) industries are so valuable. Issues in Healthcare are as real and defineable as in Manufacturing (if you disagree, read the Q&A with Dr. Bahri!)
Mark, I have been involved, peripherally, in an incident with a health care provider where a patient died. This happened due to a catalogue of errors / mistakes but in more than 5 years this is the only occasion on which someone has died. This is a single death in more than 6 million separate events. Obviously inquests took place, remedial actions were put in place to prevent those errors or similar ones from occuring again, but statistically nothing at all could possibly prevent a event similar to this from occuring. If you want to read something incredibly interesting about this type of event there is a book called Deep Survival: Who live, Who Dies and Why by Laurence Gonzales.
At the end of the day you can mistake proof and attempt to prevent errors but in some instances the only way that you find the weakness in a system is for the system to catastophically break down perhaps leading to a death. Its only once this happens that a weakness becomes identifiable and a Poke Yoke put in place. I am sure that No One could have predicted that one outcome of their current process would lead to a woman having a double mastectomy and to think that the operation resulted as the result of a single error or a small series of errors is probably underestimating the complexity and number of things that would have to go wrong in order for that to happen.
I am not being anti-lean, you know me, but one of the principles of Lean is that when a issue is identified a root cause analysis is done and a mistake proofing element put in place. Its difficult to do this before the mistake happens and in this particular case the mistake was a double mastectomy.
To the last commenter, I disagree whole heartedly. This type of mixup absolutely could have been identified previously as a risk and a failure mode. This type of error HAS happened before many times at other hospitals. Who cares if it’s one out of 6 million, it’s not like this case was a new failure mode.
I agree that sometimes something completely new can happen, but I think you’re wrong in this case. Knowing labs, this defect could have been anticipated.
Oh, and additionally, I’d like to know exactly what remedial and preventative measures were put in place, other than getting rid of the person who made the error. What proactively remedial steps were taken at all of the other hospitals that batch specimens??
Have you seen the article by Simon Dodds a surgeon with the NHS in the UK on using Lean to reduce errors and improve patient care? http://www.leanhealthcareservices.com/newsletter.html