Friday, July 9, 2010

Fixing Problems Without Blame

James Bagian is a former astronaut, aeronautical engineer, and safety expert whose latest job is trying to reduce medical errors in VA hospitals. In this Slate interview with Kathryn Schulz, he explains the different perspective he brought from the engineering world:

How does the healthcare industry compare to engineering and aeronautics when it comes to dealing with human error?

Not favorably. Much of my background is in what's called high-reliability industries—the ones that operate under conditions of high hazard yet seldom have a bad event—and people in those fields tend to have a systems perspective. We're not terribly interested in what some individual did. We want to know what led up to a bad event and what changes we need to make to reduce the likelihood of that event ever happening again.

When I got into healthcare, I felt like I'd stepped into an entirely different world. It was all about, "Let's figure out who screwed up and blame them and punish them and explain to them why they're stupid." To me, it's almost like whistling past the grave. When we demonize the person associated with a bad event, it makes us feel better. It's like saying, "We're not stupid so it won't happen to us." Whereas in fact it could happen to us tomorrow.

I appreciate that attitude, but some things really medical errors, right? Bad outcomes don't only happen because a certain piece of information was unknowable or a certain event was unforeseeable. Sometimes doctors just write the wrong prescriptions or operate on the wrong body parts.

That's true, but if at the end of the day all you can say is, "So-and-so made a mistake," you haven't solved anything. Take a very simple example: A nurse gives the patient in Bed A the medicine for the patient in Bed B. What do you say? "The nurse made a mistake"? That's true, but then what's the solution? "Nurse, please be more careful"? Telling people to be careful is not effective. Humans are not reliable that way. Some are better than others, but nobody's perfect. You need a solution that's not about making people perfect. So we ask, Why did the nurse make this mistake?" Maybe there were two drugs that looked almost the same. That's a packaging problem; we can solve that. Maybe the nurse was expected to administer drugs to ten patients in five minutes. That's a scheduling problem; we can solve that. And these solutions can have an enormous impact. Seven to 10 percent of all medicine administrations involve either the wrong drug, the wrong dose, the wrong patient, or the wrong route. But if you introduce bar coding for medication administration, the error rate drops to one tenth of one percent. That's huge. . . .

Do you punish people for failing to report serious medical issues?

No. In theory, punishment sounds like a good idea, but in practice, it's a terrible one. All it does is create a system where it's not in people's interest to report a problem.

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