THE UNITED NATIONS and the World Health Organization recently issued a joint statement claiming that the deaths of 15 children during a measles vaccine campaign in South Sudan were due to “human error.”
This is nonsense. According to facts that have been released, this tragic event is the result of decisions by people in high places, not honest human error among those administering the shots.
Medical mistakes happen for many reasons, and accident investigators usually take great care to accurately distinguish between honest human error, willful negligence and system errors. Root causes for each type of failure are different, which ought to be reflected in our responses to them.
To say that a medical mishap is a result of human error is to say that the failure stems from the type of momentary slip or lapse to which we are all prone — such as pouring orange juice rather than milk into our morning cup of coffee.
Human error is likely the culprit when a nurse forgets to swab a patient’s arm with an antiseptic wipe before inserting the needle. She knows better and may even realize right after pushing the needle through the skin barrier that she goofed.
Honest human error is common, and is actually inevitable. It happens every day, even among the most gifted health care professionals. Up to 50 percent of the nearly half a million preventable deaths that occur in U.S. hospitals each year involve honest human error.
Rushed and tired, health care professionals are prone to forget to wash their hands or double-check a medication label, and there is usually nobody nearby who is equipped to provide a much-needed reminder or nudge to do the right thing. So, mistakes are made, and patients are sometimes harmed.
Medical mishaps rarely result from willful negligence. You would be hard-pressed to find a doctor, nurse or technician who goes to work planning to harm patients by delivering substandard care. More typically, the health care system sets the stage for human error.
For example, there is a direct correlation between medical errors and the nurse-to-patient ratio on a given hospital unit. If a hospital chooses to grossly understaff a unit, blaming a lack of attention to detail on the inadequacy of an individual caregiver might be misleading.
To prevent recurrence, health care organizations must find and fix the root causes of medical mishaps. This requires a willingness to face the truth, even when doing so is uncomfortable. The joint statement by the U.N. and WHO about the recent measles vaccine debacle does not inspire confidence that such a tragedy will not be repeated.
According to a June 2 story in the Los Angeles Times, an investigation by the government of South Sudan “found that the needles were dirty, used repeatedly to inject different children, and the vaccines were not refrigerated, with unqualified workers administering the vaccinations.” The root causes of the vaccine-related deaths in South Sudan clearly reflect system issues, not honest human error.
We must not allow ourselves to be distracted by the shock of learning that dirty needles were repeatedly used; we must focus on who was allowing this to take place — especially since the program continued for weeks after problems were identified. And, we should ponder why the U.N. and WHO would jointly blame the death of 15 children on honest human error rather than addressing the system-level culprits.
This first appeared as an op-ed in The Virginian-Pilot on July 2, 2017.
Article in Psychology Today, Extradordinary People Blog
Article in Psychology Today, Extraordinary People Blog
If you aren’t worried about being hospitalized, you should be. Each year, U.S. hospitals harm 1.5 million patients and needlessly kill 440,000 — a rate of injury double what it was when federal funding was first directed toward improving patient safety.
Members of two Senate committees requested a Government Accounting Office investigation on the lack of safety progress. According to the new GAO report, hospitals face three challenges: (1) time and resources to collect information about their errors; (2) deciding which practices will make hospitals safer; and (3) ensuring consistent use of safe practices by staff.
Writing for Forbes, Leah Binder — CEO of a national consortium of business executives who advocate for hospital transparency and safety — lamented recently that health care leaders have been mum about the report. Why? According to Binder, our traditional fee-for-service payment system means “the more harm, the more payment.”
Binder characterized the GAO findings as embarrassing: “When thousands of people are dying from preventable errors, is it too much to ask hospitals to read the latest research? It’s as if the house is burning down with people inside, and the fire department is confused about which room to attack first, and which hose to use. Worse, the chief isn’t sure the firefighters will do the job.”
Binder’s exasperation is justified. The research is clear about how to eliminate many medical mistakes, including hospital-acquired infections, medication administration errors, and off-the-mark procedures (surgeries and other invasive procedures involving the wrong patient, wrong body part, or wrong procedure).
As a group, infections, medication mix-ups, and surgical mishaps represent hospitals’ most prevalent, predictable, and preventable medical mistakes — a trifecta of sorts. Strategies to prevent this trifecta of patient harm require consistent use of simple and essentially cost-free behaviors like washing hands before entering and after exiting patient rooms and using a standard time-out checklist before surgery.
Noncompliance is costly. Health care-acquired infections alone result in $28 million to $45 million excess annual health care costs. Published data have shown a 1 percent increase in the rate of hand-washing by staff will save an average-sized hospital $40,000 per year just in costs associated with a single type of infection — Methicillin-resistant Staphylococcus aureus, more commonly referred to by its acronym MRSA (pronounced mursa).
It is understandable that during the hustle and bustle of complex and complicated health care work, oversights can and do occur. Given their grueling workloads, providers will also be tempted to bypass precautions that sometimes seem too simple to matter. While fee-for-service payment may not adequately incentivize hospitals to get a better handle on oversights and shortcuts, this is a hard pill for the general public to swallow.
If more patients understood that simple habits could save hundreds of thousands of lives each year, they would demand their consistent use. Instead, critical safety steps are frequently skipped and patients rarely speak up.
U.S. hospitals have modeled their safety programs after other high-risk industries that have achieved stellar safety records, but health care is unique. It centers on people, and people cannot be controlled to the same degree as equipment (airplanes), physical structures (nuclear power plants), or material (chemicals). Hospital safety depends on consumer engagement.
Health care’s consumers become a dynamic part of the system the moment they walk, or are wheeled, through hospital doors. Although hospitals now admonish patients to speak up for safety, their approach amounts to too little too late. Offering patient education during the anxiety-ridden hospital experience is like telling a child to behave during the throes of a temper tantrum.
Long before being hospitalized, all of us must learn specific steps to take when a basic oversight is observed. When we see a nurse neglect to wash his hands, for example, all it takes is a line like this one: "I'm glad you're here. To make sure I don't pick up an infection, would you mind washing your hands?" And providers must be equally prepared to respond approvingly to such “intrusions” by patients and their loved ones.
Ironically, much of the work required to improve safety within hospitals must occur outside of them. By timely offering the public manageable steps to unite patients and providers in the journey toward safe care, we can cut the rate of harm by 50 percent within five years — a national goal that we have not come close to achieving after more than 15 years of effort.
This appeared as a Guest Column in The Virginian-Pilot:
In 2000, a group of Fortune 500 companies formed a consortium to push hospitals to reduce medical errors. They dubbed themselves the Leapfrog Group because they were on a mission to generate giant leaps forward for patient safety. Today, the group has grown to be a major player in the field of hospital safety. Its President and CEO, Leah Binder, has been repeatedly named as one of the most influential people in healthcare.
As Binder told Forbes Magazine not long ago, “I run an organization…with a membership of highly impatient business leaders fed up with problems of injuries, accidents, and errors in hospitals.”
Why do business leaders from companies like General Motors, General Electric, AT&T, Boeing, and IBM care about what happens in hospitals?
In 2000, General Motors calculated that, based on what was understood about patient safety at the time, about 500 people insured by GM would die and countless more would be harmed each year as a result of a medical mistake. Today, the calculation would be much higher.
As executives who go to great lengths to protect employees at work, the Leapfrog Group also believes in protecting employees at home. And they resent wasting company money on problems that healthcare inflicts on the workforce.
Leapfrog presses for higher standards and greater transparency to make it easier for consumers and purchasers of healthcare benefits to select safe providers. This work has made a difference, but its not enough.
For the past 15 years, healthcare has also been intensely engaged in efforts to eliminate medical mistakes, but the overall magnitude of the problem has not decreased. Healthcare knows how to prevent some of the most common medical mistakes, but success depends on greater patient engagement. Business leaders and their and employees can help with this.
A forthcoming book by the SLS President with a foreword by Binder discusses how the business community can help eliminate common medical mistakes and why doing so benefits companies, employees, and communities.
Bottom Line: each year, hundreds of thousands of employee lives and millions of company dollars are lost to hospital errors. Progress lies in mobilizing ordinary citizens to support the needed changes.
Appeared on Linkedin: https://www.linkedin.com/pulse/improving-hospital-safety-through-business-leaders-gretchen?trk=prof-post
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