‘It's never just one thing' that leads to serious error – Los Angeles Times
This is a stunning headline, it's pretty amazing (in a good way) to find an article that doesn't focus on blaming individuals.
“It's never just one thing that goes wrong when a serious event happens,” says Michael Cohen, president of the Institute for Safe Medication Practices, an organization that tracks prescribing errors and is sometimes called in to examine a hospital's mistake. “We've detailed a situation where we found over 50 mistakes in the system before an infant was killed.” The incident, he said, was a 1,000-fold overdose of the blood thinner heparin in an Indianapolis neonatal intensive care unit that resulted in the deaths of three infants in 2006.
Another interesting quote:
“People used to say that hospital mistakes are kind of like the poor — they're always with you,” says Dr. Lucien Leape, one of the authors of a 1999 Institute of Medicine report that estimated 100,000 people died each year in the U.S. from preventable hospital errors. “Well, no, they don't have to be.”
I hadn't read this next example before, the way the industry was somewhat in denial about the problem:
At first, the American Medical Assn. responded with a public relations campaign, calling the incidents “isolated” mistakes, according to an analysis of the era published in the April 27, 2002, British Medical Journal. By 1996, however, the AMA launched a National Patient Safety Foundation and changed its stance, admitting that such errors were “common.”
The good news is that many hospitals are making great strides and improvements, using improvement methods including Lean… check out the article, it's a really good overview of the situation, the history, and the successes that hospitals are having (including the infamous checklists) and the problems that still remain.
Whether you work for a hospital or a manufacturing company… is your organization still blaming and punishing individuals when systemic problems and errors occur? Or are you identifying root causes and working on true prevention? If punishing people and being careful were enough, wouldn't we have solved these quality and safety problems already? Can we do more to establish “blame-free zones” as ThedaCare has done and as described in the book Toyota Culture?
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