posted 04-12-2001 14:50            

Each year, hospital medical errors are responsible for 1 million serious injuries and 100,000 deaths in the U.S. alone. Why do so many mistakes occur-and why are they so difficult to prevent? For one thing, despite technological advances aimed at preventing problems, the complexity of our medical system can lead to human errors. For another, hospitals often fail to report mishaps, making learning difficult. Finally, the staff reductions and crowded emergency rooms that have resulted from funding cutbacks make hospitals more vulnerable to blunders than ever before.

Despite these challenges, some states are taking a leading role in reducing medical errors. For example, Massachusetts was the first state to endorse safety measures to reduce medication mistakes, the most common type of medical error. Nearly 90 percent of its hospitals have taken initial steps to minimize drug errors in their facilities, and most have stopped punishing individuals who make mistakes but rather try to understand how the wider system broke down.

In addition, the Massachusetts Hospital Association reports a growing trend in nearly every Bay State hospital to admit rather than hide errors. Dr. Lucian Leape, an adjunct professor of public health at Harvard, applauds these efforts, but warns that the more facilities look for
mistakes, the more they'll find them. He urges hospital leaders to prepare themselves for things to appear worse before they get better. Massachusetts hospitals seem to be taking this long-term view, persevering in their commitment to their patients' welfare.

Source: Larry Tye, "Hospitals Struggling to Root Out Care Errors," The Boston Globe, December 11, 2000, and "Mass. Hospitals Cite Effort on Drug Errors," February 17, 2001

posted 04-18-2001 21:05            

For the moment, I want to challenge systems thinkers who visit this forum to put on their systems thinking caps to see what they think is the root cause for medication and probably almost all health care delivery errors.

If anyone shows any interest, I will share my thoughts on the root cause.

posted 04-20-2001 10:15            

Aside from the many individual cases of errors in health care
such as similar packaging/labeling, errors in dosing,
verbal orders in noisy environments, and the like, I can think of only things
like a non-punitive error-reporting system,
or something such as lack of willingness on physician's part to implement
double-checking by pharmacists or a computer system (or physician/management
unwillingness to listen to people).

posted 04-25-2001 17:26            

quote:

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Originally posted by Black Belt:
I did some consulting work with a hospital on reducing medication errors. We got to the point that I/we understood the root cause of medication errors in that hospital and in all hospitals. Unfortunately, the CNO's resolve ran out and therefore the funding for the effort evaporated. However, it became quite evident to me that the root cause is straightforward to identify.

For the moment, I want to challenge systems thinkers who visit this forum to put on their systems thinking caps to see what they think is the root cause for medication and probably almost all health care delivery errors.

If anyone shows any interest, I will share my thoughts on the root cause.

---

Do I understand correctly that you are speaking of THE root cause, as in, one cause that is both necessary and sufficient? If so, this seems to rule out feedback loops. From the rest of your post and question/challege I doubt this to be your basic assumption.

Can you clarify/elaborate of your question?

Thank you,

Bill Braun

posted 05-03-2001 11:55            

I am talking about THE root cause, and I believe it is the assumption (on the part of people who design and operate the process and implementing system that is used to deliver medications) that we are all human and humans make errors. This assumption hinders the feedback loops that enable double loop learning. As long as this assumption is alive and well, people will not design and implement an error free process.

One of the training videos that is used nationally for nurses delivering meds shows in the very first scene a nurse saying, "We are all human and humans make mistakes." This scene immediately frees nurses of the burden of delivering meds error free. In an "error free" culture this statement would never be made.

At DuPont which has a safety culture, the mantra is "All accidents are preventable." DO they have accidents? Yes. But the mindset of all employees is that accidents are unacceptable and processes and systems are put in place to prevent accidents and to learn from accidents, near misses, and minor events.

The "learning," if one can call it that in most hospitals is superficial. The reporting mechanisms and lessons learned are seen as a perfunctory responsibility to meet JCAHO or some other administrator's requirements. However, very few hospital workers (includes managers and execs) understand the effect that their assumptions have on the processes and implementing systems they create and operate.

Your thoughts.

posted 06-21-2001 19:46            

quote:

---

Originally posted by Black Belt:
Sorry I haven't posted a response earlier. I was focused on preparing for the US National Masters Judo Championships held 4/28 which I won in my division.

I am talking about THE root cause, and I believe it is the assumption (on the part of people who design and operate the process and implementing system that is used to deliver medications) that we are all human and humans make errors. This assumption hinders the feedback loops that enable double loop learning. As long as this assumption is alive and well, people will not design and implement an error free process.

One of the training videos that is used nationally for nurses delivering meds shows in the very first scene a nurse saying, "We are all human and humans make mistakes." This scene immediately frees nurses of the burden of delivering meds error free. In an "error free" culture this statement would never be made.

At DuPont which has a safety culture, the mantra is "All accidents are preventable." DO they have accidents? Yes. But the mindset of all employees is that accidents are unacceptable and processes and systems are put in place to prevent accidents and to learn from accidents, near misses, and minor events.

The "learning," if one can call it that in most hospitals is superficial. The reporting mechanisms and lessons learned are seen as a perfunctory responsibility to meet JCAHO or some other administrator's requirements. However, very few hospital workers (includes managers and execs) understand the effect that their assumptions have on the processes and implementing systems they create and operate.

Your thoughts.

---

Now it is my turn to apologize for the delay in responding.

I find your hypothesis of THE root cause intruiging. On one hand, it is hard to argue that it is not both necessary and sufficient to explain medical errors. You are describing a pervasive and deeply held mental model. I concur with your aseesment; it may very well satisfy the criteria of being both necessary and sufficient.

Where I find it weak is in its apparent lack of a connection to organizational and/or managemenbt structure. Respectfully offered, it seems that you are saying that if they stopped giving permission to nurses to make errors (because they are human) the errors would cease.

Attitude, as you point out, is indeed powerful. That is, I would concur that it is a necessary component/element of reducing medical errors. As to its sufficiency, I have grave doubts. I think it must go beyond attitude and encompass the policies and processes that govern transactional behavior in organizations.

Could you expand on your hypothesis? Am I missing a dimension of it that makes me see things differntly?

Bill Braun

posted 08-16-2001 11:15            

quote:

---

Originally posted by Black Belt:
Hello, Bill. Thanks for your thoughtful and articulate response. I am not hypothesizing that by taking away the OKness of nurses making mistakes that they will stop. Rather, I agree with your thought that as executives, nurse managers, physicians, and nurses, it is important that they adopt an attitude that all errors are preventable. From this attitude then, they can learn to build what I call an "error free zone" that is a mindset as well as policies, procedures, and implementing technology. If a nurse were practicing in an error free zone, she/he would be the last line of intelligent defense (possibly in league with the patient and patient family)in preventing any error prior to med delivery becoming an actual error in the med delivery. Even this approach will not completely eliminate errors, but it will set a foundation for moving to 6 sigma performance and that would be quite an achievement. If you would like to talk about this, you can call me at 678-795-9555. Ask for Willard.

---

Hi Willard,

Have you developed a CLD for this? I think it would be a good exercise to explore the view points we have and invite others to participate as well. Speaking of Six Sigma, Mark Chassin wrote an article in the November, 1998 issue of The Milbank Quarterly entitled, "Is Healthcare Ready for Six Sigma". And more recently the Institute of Medicine, of which Chassin is a member (if not on the Board) has issued their reports.

I'm still wrestling with this "the root cause" concept. It seems to me that in a feedback system there is no one root cause. There are most certainly variables that have much higher leverage potential than others, but drilling down (over, up?) to the one root cause seems to defy a basic tenet of system dynamics. Have you read any of Jay Forrester's works on SD? I'd be interested in hearing your thoughts on Forrester's SD work and the one root cause hypothesis.

Best regards,

posted 09-04-2001 11:44            

Willard

Admin note: Willard graciously permitted us to post the diagram to accompany his note.

posted 08-30-2006 04:32            

With regards,
Mandar Thosar