Here is the second short, simple Kaizen education video from KaiNexus. You can view the first video here and the entire series. We are embedding these videos into our web-based software, to provide short tips and hints for our users. We're also making the videos available on our YouTube Channel. Subscribe to our channel to be notified of each new one that's released.
This video addresses the topic of looking at systems and processes, rather than just blaming people.
Video updated September, 2014 – View on YouTube
The ideas in these videos are elaborated on in my book Healthcare Kaizen: Engaging Front-Line Staff in Sustainable Continuous Improvements.
Approximate transcript of the video:
Hi, I'm Greg Jacobson from KaiNexus.
Lean thinkers and patient safety experts agree – most problems and errors are actually caused by deficiencies in our processes and systems. Remember the case a few years back when the actor Dennis Quaid's twins were given an adult dose of heparin in the ICU? Would it make sense to simply reprimand the nurse? Well, the Quaid twins were actually given that wrong dose by 3 different nurses over a 24-hour period. They weren't 3 “bad nurses,” the situation points to having a number of systemic errors that occurred, in the pharmacy and the unit, that even allowed the adult dose to be there in the NICU.
The modern patient safety movement emphasizes the need to prevent errors and harm by focusing on our processes, not just getting rid of so-called “bad apples” after an error has occurred. See the book To Err Is Human: Building a Safer Health System from the Institute of Medicine for more on this topic.
So here's your call to action – as you go through your daily work, proactively look for things that COULD go wrong… these could be near misses or it could be unsafe conditions that could cause harm to patients or staff.
When you see one of these, take a few minutes and log into KaiNexus to report the Opportunity for Improvement, whether you have an idea for a countermeasure or not. Let's say you discover two medications with similar names that also have very similar looking packaging – that's an opportunity for improvement. Or if you find a medication in the wrong location, don't just put it back where it belongs – report the problem so your colleagues can work to prevent that problem from occurring in the future.
Identifying problems and risk factors is the first step in process improvement and it's an important step in moving toward zero defects as a goal in our important healthcare work.