Thursday, July 10, 2014

Learning from Near Miss Events to Avoid the Catastrophe

In my April 3 blog post, I discussed the notion of preoccupation with failure and that accepting a defect by working around it may eventually lead to a catastrophe. High reliability organizations demonstrate a zeal to fill holes in the Swiss cheese before they can line up to create a bad outcome. When they find a defect they do work around it but they also identify the root cause and redesign it so that the problem doesn't occur again. They don’t fall into the trap of working around the problem over and over again until eventually other defects line up and a patient gets hurt.

On Lean Daily Management rounds last week one of our units reported a missing dose of insulin from the day before. A nurse went to give a patient insulin at 6:00 a.m. However, the insulin, which had been ordered more than five hours earlier, was not there. The nurse, concerned that the patient was about to eat breakfast and the risk of hyperglycemia quickly called the pharmacy who raced to deliver the medication. Further problems were averted and the staff breathed a proverbial sigh of relief. 

But what happened next? The staff, both on the floor and in the Pharmacy went back to their work. When I asked the person presenting the board what did they learn as to the reason why the insulin was not there the answer was that they did not know because no one as yet had investigated it. Now before you as the reader get upset with me and say “there he goes again, this guy doesn't know how hard the nurses and pharmacists are working…when did he expect them to study this?” - I accept your criticism. We leaders must create the capability to study these errors in real time if we are serious about fixing the “latent” errors that lead to near misses and then sometimes to full-blown catastrophes. We must create both the zeal to learn why the defect occurred and the resource to study it and fix it as quickly as possible. Eventually some patient may get hurt because we didn't learn why this patient dodged a bullet. 

We are making excellent progress toward our vision in our healthcare system. But the question remains what can we do to move faster? One answer is to be preoccupied that if we don’t learn why a defect happened someone could get hurt and be less likely to work around a defect in our system and go back to work.

I welcome your comments.

8 comments:

  1. I think it's understandable that the staff couldn't investigate the matter right away, but perhaps could they write up a brief incident report and then the appropriate quality staff investigate? How would a near miss like this normally be handled - is it considered an incident?

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  2. To ask me, as the RN, why the pharmacy didn't send insulin in a timely manner, is futile. It's like asking me to find out why Target was out of paper towels. Has anyone from the pharmacy addressed what's going on up there? Are their processes the right ones? Are they adequately staffed to meet demand? I've worked here a long time and seen a lot of turnover in that department. It just doesn't seem to get better unless you're a unit with missing meds on the LDM board. They get the attention.

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    1. Thanks, Anonymous. It is not true that missing meds have been reduced only for units that have it on the LDM board. They have been reduced house-wide. To use your Target example, the person stocking the shelves at Target doesn't know why they are out of them either, until she investigates and finds the cause so that it doesn't happen again. I am very proud of our staff who are taking the time to learn from the defect and fix it. Nurses working together with pharmacists have made things much better for all.

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  3. Dr. Chessare, as a nurse who has worked on busy units, and currently deals with patients who have issues in the outpatient arena, when a problem presents itself I work to find out why, and fix it. When someone didn't find out what the problem was when the issue arose in the first place, it can cause problems for the current patient, the next nurse, the next patient etc. Personally I do criticise those, who are presented with an issue, sometimes repeatedly, and do not take the time to check into it. If you spent the time working to resolve the issue, instead of spending as much energy working around it, more problems would get taken care of. What I find is that too many think that the next person will handle it!

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    1. Thanks, Anonymous for exploring the cause of the problem and fixing it before it leads to a bad outcome for the next patient.

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  4. I think that a portion of realizing potential catastrophe in patient care comes from outside of the hospital. There may be stress and chaos that comes from our children, spouses, the morning traffic, or our personal health that may cause stress, or a distraction while at work. It isn't accounted for sometimes, and things like this influence how we all perform in the work place. I think that there should be sessions in which we are able to learn and discuss ways to separate outside pressure and stress. I think in doing so we eliminate some of the gray areas in the 'Swiss Cheese' philosophy. I know from personal experience as a mom, student, entrepenuer, and employee of this institution. Problems like these are real and relevant inside of the hospital and should not be ignored.

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    1. I agree with you Anonymous. One of the protective walls in Professor Reason's model is the intelligence and preparation of the people involved in the system. One of the latent errors or "holes" in this layer is issues that cause the person to be distracted. Clearly, personal issues are a large source of reasons for distraction. Do you have ideas of how we can help those who are going through problems outside work to reduce "outside pressure" and stress?

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