"Root Cause" in the News

In my morning reading yesterday, I was pleasantly surprised to see the phrase “root cause” in two stories I've written about here:

• Preventable Medical Errors (free, Modesto Bee)
• Deadly Products from China ($$, WSJ)

I have a post I've written, but haven't published, about how China recently executed the corrupt head of their pharmaceutical approval board for taking bribes to approve untested drugs that proved to be deadly. While his actions were despicable, I asked if killing that man really solved the “root cause” of what seems to be systemic corruption and unregulated greed that's leading to a slew of negligently harmful or deadly products made in China (toothpaste, pet food, tires, shrimp, monkfish, baby toys, cell phone batteries, etc.).

On that item first, the WSJ had a column that talked about that systemic culture of corruption in China and their willingness to ignore quality in the name of profits. Take this latest case of a Beijing vendor who was putting chemically treated cardboard into dumplings sold on the street. It's not just the stuff they are exporting. Chinese are doing this to fellow Chinese. How can this be? I don't buy the excuses of “They're a developing nation, of course they're going to behave this way.” I'm sure the Chinese who are cutting corners KNOW they are doing wrong. I don't think it can be explained away as ignorance or the “growing pains” of capitalism.

The article says:

The chaos of communist rule over the past decades — from famines to purges to neighbors informing on one another — has also likely contributed to the blurring of moral distinctions. “The Cultural Revolution created an enormous dent in morality. Society [was] in confusion for a long time. Couple that with the madness of trying to get rich — you put these things together and you end up getting contaminated toothpaste and pet food,” says Peter Humphrey, longtime China hand and founder of risk-management consultancy ChinaWhys.

William McCahill, a 25-year Foreign Service veteran who is now managing partner of JL McGregor and Company, a China-focused research and advisory group, explains: “There is no sense of social solidarity that would tell you: I put this stuff in and maybe children are going to die.”

I've always joked that if you ask “why?” six times (one more than the famous “5 Whys”), you end up blaming society, and that isn't very helpful. But it seems to be the “root cause” pointed to in China.

The article describes “widespread unethical practices.” Will the execution of the one bureaucrat scare others in shaping up? What happened to intrinsic ethics? What would Deming have said about this attempt at quality and ethics through fear?

Now let's turn to the medical errors article. You can click on the link to read it, it's a free article. Long story short of the scenario:

“…her surgeon was talking with her husband about something unusual that had happened during the surgery a few days earlier.

Her husband, Gary Baumgartner, couldn't believe what he was hearing. The surgeon said he had operated on his wife while using a different patient's angiogram films.”

Now, the typical reaction might be to blame the surgeon, the techs who handled the films — punish, blame, and maybe fire.

What jumped out at me was that the reporter actually brought up the question of root cause and prevention. Brilliant! We rarely see that in news stories:

After serious mistakes, hospitals are supposed to do a “root cause” analysis, focusing on conditions and events in the hospital unit that day. Was there poor staffing in the cath lab? Had the employee worked a long shift? Was there a quick call for the films?

Any solution that simply asks employees to try harder is a recipe for more mistakes, Haraden said. The hospital should work on addressing the environmental factors that led to the error.

“Anytime you have a handoff there is a risk,” she said. “One way to make the system more reliable is reduce the number of steps.”

I hope the hospital is actually putting some root cause prevention measures in place. But what about sharing information with other hospitals? Why isn't information shared so that NO OTHER hospital makes the same mistake?

The good news is that the “root causes” of the hospital error are going to be a lot easier to fix than the root causes of China's quality crisis.

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