Hospital errors strike again (and again and again and again!)
By Mike Thelen:
Having spent the last 10 years working within Lean disciplines, it is second nature to identify shortcomings in any business model from a Lean perspective. Since I also have two individuals in my immediate family who work in healthcare, I tend to *find* many opportunities for Lean simply by listening to dinner conversation. Thus, when articles like the following cross my homepage, they seem to demand my attention.
Sep 19, 8:18 PM (ET)
PROVIDENCE, R.I. (AP) – State health officials were investigating how a surgeon operated on the wrong knee of a patient Friday at the Miriam Hospital, part of a medical network that was reprimanded and fined $50,000 last year for three mistaken surgeries at another of its facilities.
The medical network had reprimands and fines, but no mention of problem solving by root cause evaluation. Did reprimands and fines do anything useful? The results are obvious, repeated errors mean no benefit from paying a fine and a severe lack of problem-solving techniques to avoid repeatable errors.
The latest mistake happened while a surgeon performed a knee arthroscopy, a procedure in which doctors insert a pencil-sized camera into the knee so they can diagnose a malady. In some cases, surgeons will repair or remove damaged tissue.
After the operation was complete, the surgeon realized the mistake and operated on the correct knee, hospital officials said.
What about the added expenses to the hospital: time, delays, supplies, lawsuits, etc? How will the patient react and how long will his recovery now take? Healthcare coverage is a constant election-season topic. How about the added costs that will be driven back into insurance coverage (we all know this will happen, either directly or indirectly)?
Miriam spokeswoman Linda Shelton would not identify the doctor or patient, whom the hospital said was “doing well.” Lifespan, the not-for-profit corporation that operates the hospital, has started an investigation into the accident.
Will the investigation utilize the scientific method of problem solving or the traditional management method of assigning blame and reprimanding? By their own admission, past experience indicates the latter, not the former. So, can we expect to see the same repeatable and completely avoidable error again in a few months?
“We deeply regret that such a mistake occurred,” Lifespan said in a written statement. “We have apologized to, and are working closely with, the patient and the family.”
The state Department of Health was alerted to the mistake Friday and sent a team to investigate, department spokeswoman Helen Drew said.
The jury's still out on the benefits of sending a State team to investigate. I have a relative who works in a State department with a similar function. Usually, those situations are just like industrial inspections. Everyone knows “who's coming for dinner” and all employees are prepped for the appropriate responses to questions. This is often best described as pre-tour 5S activity, as opposed to everyday clean to inspection that 5S truly desires.
“We're obviously greatly concerned about the incident and the patient,” she said.
Lifespan revised its policies following a string of wrong-side surgeries at Rhode Island Hospital, a teaching facility for Brown University's medical school.
Revising policies. I guess that should make us all feel warm and fuzzy. How about solving problems? Take a team approach. Honestly, seek out opinions from all areas of the organization. Ask the 5 why's to get the true cause out in the open. More so with the evidence of repeated and continued mistakes with “a string of wrong-side surgeries”. Should we as the paying public be even more terrified that these completely avoidable mistakes are occurring at a teaching facility?
In November, the chief resident started operating on the wrong side of an 82-year-old patient's brain, health officials said. A different doctor performed neurosurgery on the wrong side of another patient's head in February.
In August, a patient died several weeks after a third doctor operated on the wrong side of his brain. Afterward, state health authorities ordered the hospital to take steps to avoid similar accidents in the future, including an independent review of its neurosurgery practices and better verification from doctors of surgery plans.
Verification? Sounds more like quality inspection. How can you remove the inspection process by building in quality? That should be the true goal. Does it really benefit anyone when an agency, or a person in a leadership position (not necessarily a ‘leader'), orders action to take place? How about working together without fear of reprimand to resolve an issue that, in this case, can honestly be life or death?
We (both members of the Lean community and hospital patients) should be outraged. How many times can the same mistake be repeated? Someone died from the same, avoidable error. The cost of healthcare (not to belittle a death) also gets driven up in an environment that is already cost-heavy. How much trust can, or should, patients have in this hospital system?
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