"More Careful" or "Better Processes"?


NHS: 60,000 medication blunders in 18 months – Health News, Health & Wellbeing – The Independent

Trust me, I'm not picking on the NHS. There's a lot of good things happening here with Lean and I'll blog about some of that soon.This article from the Sunday Independent highlights some numbers on medical errors:

Medication blunders by NHS staff are killing patients at a rate of two a month and costing the health service £775m a year, a watchdog has revealed.

The National Patient Safety Agency (NPSA) has found that thousands of patients are being given the wrong drugs, too little or too much of their prescribed medication or miss doses altogether.

The study found 60,000 “medication incidents” were reported by hospitals, GPs, pharmacists and community health centres over 18 months up to June 2006. Thirty-eight patients died as a result of these mistakes and a further 54 were dangerously harmed.Experts believe that fewer than one in 10 cases are reported, suggesting that there may have been as many as 708 deaths out of one million incidents.

When you look at patient safety or medical error problems across the United States, Canada, and the U.K., they're roughly the same on a per-capita basis. It's not like any country is an order of magnitude better or worse than others. The operational processes tend to be the same across countries, leading to similar results, regardless of the payer system involved.

The response to these errors? We need more “Lean thinking” than what's demonstrated in the following quote:

These findings come a week after the NPSA Rapid Response Report which urged “extra care” when administering powerful drugs such as morphine, amid concerns incorrect dosing had caused several deaths since 2005.

As I've blogged about before (and write about in my book), “being careful” is not enough. Being careful is a good start, but bad processes and bad systems can defeat even the most careful of individuals. Urging staff members to be more careful, in my view, is unlikely to do much long-term good. Firing employees after the fact of an error doesn't do anything to improve the underlying processes.

If a process was error-prone, someone else is likely to make that same error again. If you could proactively identify which employees or physicians are likely to not be careful, those who going to cause an error, then just proactively fire those people. Problem solved right? Not really. We don't have that ability, so we'd better focus on processes and systems… not just “being careful.”

The Lean approach urges us to create “error proofed” processes. Toyota and Lexus don't have better quality because their people are “more careful.” It's all about systems and processes.

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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. I was having a chat with someone yesterday about a staff member that is currently under investigation for administering a out of date drug to a patient.

    We were talking about the staff members responsibility for not reading the date on the label but how it is not only their fault but that the medication should simply not have been in the pharmacy refrigerator allowing the opportunity to take the out of date drug.

    As a vociferous defender of the NHS :) I have to say that a problem that we have versus the rest of the world is that we are by and large compelled through statutory bodies to reveal our issues where as other systems are not compelled in the same way. It is therefore easy to suggest that because it is a public system that it is poor at a variety of things but this is simply not the case.

    I think being open and honest about the errors is an excellent step in the right direction and whilst some will condemn you and suggest that its being done for less than forthright reasons (a charge levied at Levy (thats funny)) such as trying to reduce liability claims and others will charge that its a cover up when you are not open and honest. I think that putting the data out there and making public the failings of the system will lead to positive changes in the way that health care is delivered.

  2. I absoluely agree with andrewmc about bringing errors out in the open. We all need to do that (the “transparency” argument) so we can see the extent of our problems. If we repeatedly make mistakes and hide them, we can’t address them. And we need to bring the mistakes to the surface in a forthright manner with the intention of addressing real solutions.

  3. I’m a Lean specialist in a large health system in Iowa. We’re just getting started with Lean at a system level (we have many activities going on with our member hospitals), so it’s exciting to be able to bring the Lean philosophy and tools to a wider audience.


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