Flashback Friday: Demolition Errors, Mistake Proofing, and Healthcare
In recent years, I've written two blog posts about the sad (and full preventable!) scenarios where the wrong building was demolished by a crew.
In these scenarios, it's easy to blame “bad crew” instead of looking at systemic causes of such an error. Having a better process is always more effective than admonishing people to “be more careful.”
And from 2016:
It's clearly not practical to write NO!!!! on every home or building that is to not be demolished.
That's why this scene caught my eye when driving in Orlando recently… a shopping center is apparently going to be demolished in the near future:
If a demolition crew were to show up at the wrong shopping center… let's say the right street address on the wrong street, NOT seeing “DEMO” (or seeing businesses that are open instead of shuttered) would hopefully clue them in about their error.
This seems like a good practice:
- Somebody (demolition company manager?) marks the correct property
- Allow some time to pass (a day or a week?) to allow somebody to speak up if the property was marked in error
- Have the demolition crew show up and ONLY knock down buildings marked “DEMO”
That would create a bit of delay in the demolition “value stream,” but I'd hope demolitions are planned and scheduled anyway. Do it right the first time, eh?
Demolish it right the first time… or demolish the right place the first time.
A few days later, my Lyft driver was taking me past that spot on the way to the airport and I saw the buildings. The Lyft driver had asked about what work I do and, as we were talking about improving healthcare (safety, quality, efficiency, waiting times, cost, employee environment… all of those interconnected goals), I pointed out the buildings and “DEMO.”
He was dumbfounded that the wrong building could ever be knocked down. I asked him, “How often do you think the wrong surgery gets performed on the wrong patient?” That was less funny to him.
Wrong site or wrong side surgeries are supposed “never events” that still happen too often.
Some reading on this topic (surgery, not building demolition errors):
- Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery
- Joint Commission Updates Sentinel Event Statistics
- Wrong-Site Surgery Cited as Top OR Safety Challenge Among U.S. Hospitals, Survey Finds
The causes of wrong site demolition or wrong site surgery are probably similar…
- poor communication
- people being rushed and under pressure
- a “just get it done now” mindset
- bad processes
- a lack of error proofing
- not pointing out near misses in a way that could lead to fixing the process to prevent future mishaps
How could these concepts be applied in your hospital or your workplace? Where do you see “dumb mistakes” being made? How can we prevent them, since people aren't dumb?