Digging Deeper to Reduce Medical Errors

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If you don't reach the root cause, you're not likely to solve the problem.


learn from a mistake LEARNING FROM MISTAKES Unless you get to the bottom of why a mistake happened, you're likely to repeat the mistake.

When we ask why a medical error happened, it's easy to settle for the first answer. Because someone was distracted. Or someone was tired. Or because we were behind and felt pressure to hurry. But answers like those typically just scrape the surface. If you want to make sure an error doesn't happen again, you need to keep digging. Why was that person fatigued? Why were we behind? Is there something here that we can control? Is there an awareness we can teach and learn from? The goal with root-cause analysis is to keep asking why until you can't go any further.

In health care, answers tend to be multi-factorial. A lot of things may contribute to a given problem, but if you don't investigate thoroughly, and really get to the bottom of why something happened — and take corrective action — you won't fix the problem. You may acquire some sense of how or why things went awry, but if you don't get to the root cause, quite possibly, maybe even probably, the error will happen again.

Zero isn't realistic
We've all heard the staggering numbers. Hundreds of thousands of often-fatal medical errors happen every year. We're constantly exhorted to think in terms of "never events" and to reduce the number to zero. To me, that's misguided. As long as humans are involved in any process, there are going to be errors. Instead, our focus should be on zero avoidable errors. That goal, I believe, is attainable if we implement better reporting systems and better means of following up.

Unfortunately, the root cause is often missed in health care, where reporting tends to be poor, analysis tends to be late and errors occur so frequently that by the time we start to think about the root cause of one, we're forced to deal with another. Many are avoidable, but we don't get the chance to figure out how because we're too busy dealing with the next incident, and then the next.

Practitioners often say, "You don't understand, our industry is different, patients are more complex," and so forth. It's true. You're functioning in a very complex environment. But if you're determined to really systematically address mistakes, get to the bottom of what caused them, and try to put corrective actions in place, you can make a difference. The alternative is that somebody puts a superficial or temporary fix in place — one that doesn't address the root cause — and everything seems OK again, at least for a short time. But then, when things heat up again, no proper corrective mechanisms are in place, and everybody's surprised, because the mistake happens again.

The bottom line is that we need a cultural transformation in the way we approach and think about medical errors. Since we know they're inevitable, what can we do to eliminate as many as possible? The answer is that we can do several things — some easier than others.

First and maybe most importantly, we need to make reporting as easy as possible. Information is critical. Anyone who sees anything that raises concerns needs to feel as if she can easily pass that information up the chain of command.

The ability to report should reside on every computer in the facility and should provide the option to remain anonymous. You want to make it as quick and easy as possible for people to report the basics — the who, the what, the where and the when — in 2 or 3 minutes.

The reason: If you have a single report on a single incident regarding a single patient, it may be tough to make an evidence-based decision as to whether it's something that warrants further investigation. But if you have 5 or 10 reports of the same thing happening, you know you'd better get to the bottom of it.

Granted, it may seem like a double-edged sword. If you make reporting easier, you get more reports, and that may make it feel as if you're doing badly. But in an industry that demands high reliability, like aviation or health care, you need information to be able to make decisions. People sometimes make the mistake of thinking that a paucity of reporting is an indication that things are working well. The opposite is true. If you don't have people reporting on things that can be improved, chances are you don't know what's going on. Everyone should be urged to say something whenever they see something. And they should feel safe and appreciated for doing so.

WHY DRILL DOWN?
Assumptions Often Turn Out Wrong

caregivers NEVER AGAIN Caregivers are likely to be more receptive after they make mistakes they thought could never happen.

When medical errors happen, it's tempting to jump to conclusions about why or how they happened — and whether anything could have been done to prevent them.

That's one of the reasons root-cause analysis is so important, says Kathy Wilson, RN, MHA, VP of quality for AmSurg, whose duties include gathering information and implementing corrective actions for about 250 ASCs nationwide. "Once you start doing a root-cause analysis — drilling down into the why — quite often your preconceived ideas turn out to be different than what actually occurred," she says. "You have to dig in and talk to people at the centers who are doing the work to get to all the contributing factors."

It may be easy to say something was the result of human error or equipment failure, and leave it at that, but is that enough to prevent a mistake from happening again?

"We just had a problem this week where it turned out that the person who usually completes one of the safety checks on a machine was out on medical leave, and no one assigned a person to replace him," says Ms. Wilson.

But now, armed with that information, the center can enact a policy to make sure all employees are covered in the event of an unexpected absence.

— Jim Burger

Overcoming obstacles
The big picture is one in which we need to do a much better job of promoting communication in general. And note that communication doesn't have to be negative. I would like to see everybody get together at the end of every day and each mention one thing that went well and why. You can then aggregate those things and incorporate them into your training, knowing that they led to better results.

But there are obstacles to overcome. Physicians have great technical knowledge and skills, but many have little or no education regarding leadership. They aren't taught how to bring their teams together and make sure they're working together. One result is that team members are often afraid to speak up, to talk about what they hear and observe in ways that might help the team. Fear of litigation is of course also a very real concern.

But anything that impedes communication is self-defeating. We know that everyone involved in health care cares about their patients and wants good outcomes. We need to appeal to that instinct — to say that if there's a very high probability that something bad is going to happen to your patients, and you can do something to prevent it, you must do what you can. OSM

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