Fixing Medical Errors - 10 Effect Strategies in Reducing Specimen
Collection Errors
Fixing
Medical Errors: What Works? (Research
Report Phase III)
10 Basic Principles of Process
Redesign
In the process of fixing medical
errors, other very important stages preceded the phase of solution implementation. Before
getting to the implementation phase, problems leading to medical errors should be
identified. Root-cause analysis should be conducted to identify other factors involved. A
study should be done to determine the frequency of the problems and the relevance to
patient care. Solutions should be designed using an action task committee with specially
selected members. This phase of our report is reporting
on solution implementation.
Although it is quite possible
in some cases for one person to complete all the phases prior to solution design and
implementation, depending on the problem under question. In most cases, it is strongly
suggested that all stages should be done using a group approach of the task force
committee. However, if for any reason the task force committee is not being used from the
beginning of the project, at the solution design and implementation phase, the group must
be used. Otherwise, the process may start failing from here. Poorly designed process
causes frustration for employees. Increase work frustrations will force many good
employees to leave. The lone-ranger strategy of the big boss trying to solve medical
errors has been responsible for the lack of progress and many failures seen across the
country. Health-care industry is a very rigid system and there are a lot of problems
associated with the present operations. Workers with titles and big degrees make as many
errors as those with certificates and small degrees. Although the power of education and
titles make professional workers more arrogant, and at times able to collect hefty
salaries, by no means do they prevent a person from making a deadly mistake.
Those who claim they know your
work better than you, are not only bragging, they are also telling a big lie. No matter
the crowns they wear or the elegance offices they sit in, nobody knows your job better
than you. There is no way one person who does not work on the process-line can
successfully redesign and implement solutions for those working on that line. Health-care
delivery is divided into many process-lines. Only those working on each of those lines are
capable of redesigning their work process. Many successful businesses across the nation
are now beginning to move away from the strategy that the big boss with a long tie, thick
glasses and gray hair has all the answers. This false notion is presently creating many
business failures. Instead, more successful businesses are moving towards
employee-engineered redesign based on the needs of the customers. Many health-care
institutions are still stuck with the old idea and are paying dearly for this with
continuous revenue loss. The easiest way for a person to lose his life is to jump from a
flying plane without knowing how to use a parachute. No matter the title of his office or
the degrees behind his name, when he hits the ground without his parachute flying above
him, he will explode into many pieces. Medical errors respect no titles or degrees; they
infect everybody equally. The bigger they are, the harder they fall. Many outstanding
physicians and health-care workers have been brought low because of medical errors.
Prior to the implementation
phase, the solutions have been designed by the task-force members. Before thinking about
general implementation, solutions have been pilot tested, and the result is showing
positive outcome. For more detailed information about the entire strategy designed to
reduce and prevent medical errors, get a copy of 101 Ways to Prevent Medical Errors
or visit the site: www.101waystopreventerrors.com
for a report on our ongoing study.
Briefing
on the Giant Success Achieved from this Study Up-to-date
During the solution-implementation
phase, we are working with three major institutions regarding medical error reduction and
prevention. Our interest is to find out what works by looking at those conditions that
foster successful implementation of solutions.
Health-care Institution
#1
In the first health-care institution was
a program designed to reduce physicians’ misadventures. The hospital was losing a lot
of money because of medical adventures that did not improve the clinical outcome of the
patients. The result of the patient-satisfaction survey was not at the level the hospital
wanted. In response to these problems, a group of physicians formed a committee to write
standardized protocols for treating some common diseases based on the opinions of the
leading experts in the field. Initially, some older physicians resented the idea, but
after many physicians discovered the usefulness of the up- to-date information, the idea
became gradually supported by the entire medical staff. The Physician Monthly Review
created by this group of physicians shares the latest information about treatment success
and treatment failures to other physicians based on national experts in the field. The
experts’ opinions included the latest journal articles and information from the
latest seminars. Six months after the program implementation, there was an increase in the
quality of patient treatments with a 30 percent decrease in mortality rate. The number of
misadventures by physicians dropped to less than 10 percent compared to the number before
the program was instituted. The hospital also reported more than three million dollars
savings during that time period.
Health care Institution #2
The second health-care institution,
was located in a working-class neighborhood. Most of the patients had jobs, and a good
percentage of them had medical insurance coverage from their jobs. The hospital also
negotiated a price-cap contract for emergency room visit for a group of patients. In such
a case, regardless of the reason for the patent’s visit to the emergency room, the
hospital received a fixed payment. This is a very busy emergency room with an average of
68,000 visits a year. Despite the large number of visits, the hospital was not making any
money because most of the revenues were consumed by operational costs. After a three-month
study of the operation of the emergency room, many money-wasting situations were
uncovered. It was observed that anybody from nurses, techs and paramedics had been
ordering tests on patients based on what was defined as the standing protocols. Some tests
were also ordered at the discretion of non-physicians without the initial approval from
physicians. Patients who came with scratches on the forehead or little bumps and bruises
received elaborate orders including X-rays, lab tests, and other unnecessary tests. The
shocking part was the unnecessary “type and crossmatches” ordered on all these
patients. In was also observed that “urinalysis test with culture” was initiated
as a standing order even when the urinalysis result indicated absence of bacteria or white
cells. These were just few examples of the money wasters from the emergency room’s
operation.
In response, a group of
physicians, nurses and paramedics as well as representatives from the pharmacy, lab and
X-ray departments formed a task-force committee. The committee as assigned the job to
redesigning the emergency room’s way of ordering tests on patients. Before any test
was ordered on a patient, a physician must first see the patient. Other than by a
physician, standing orders can only be instituted by a nurse in case of an emergency. The
task-force committee also defined what tests can be
ordered STAT because the lab complained about the indiscriminate ordering of tests that
were not STAT eligible from the emergency room. Every physician is supposed to adhere to
the new policies. These new strategies of operating the emergency room decreases the
number of unnecessary tests that had led to a waste of the hospital’s revenue. Eight
months after the new policies were instituted, the emergency room started saving an
average of $79 operational cost on each patient. If everything continued to work according
to plan, the hospital had a projection of $5.4 million savings per year from the emergency
room.
Health care Institution #3
In the third health-care institution,
the hospital lab was receiving many mislabeled and unlabeled specimens from the nursing
department. Emergency room and Intensive care units were the biggest offenders. It
appeared as though these two nursing units created barriers of resistance against external
interventions from the lab. Other problems associated with specimen collection tended to
cause a delay in patient treatment because the specimens had to be re-collected. Most of
the causes for specimen rejection were due to mislabeled, unlabeled, hemolyzed, clotted
and inadequate specimens. However, poorly aligned barcode labels were causing delay in
reporting tests. The techs were having to stop to reprint the labels before replacing them
on the tubes. All these specimen collection problems were not only decreasing the quality
of patient treatment, they were costing the hospital a lot of money. It was estimated that
any lab test to be redrawn was costing the hospital $40 per test, based on the time and
the manpower needed to redo the entire process. This redoing process, even though it costs
the hospital money, is not billable to the patient. This
particular hospital had about 300 - 400 specimens to be recollected per month, costing
$12,000 - $16,000. The annual non-billable cost of redrawing blood was from $144,000 to
$192,000 excluding the cost of disease complications and patient suffering caused by delay in treatment.
The hospital administration was
so concerned about these problems that a task force was set up between the lab and the
nursing department. This committee was designed to help reduce specimen collection errors
and to help update the nursing staff members and teach them the appropriate ways to avoid
specimen collection errors. While working with the nursing staff, the lab also learned
some of the processes of nursing operations to help design better cooperation between the
two departments. It was previously believed that the goal of reducing specimen collection
errors was unattainable. Halfway through the campaign to reduce specimen collection
errors, a pilot study was conducted to test one issue and evaluate whether there are
responsive forces in place before the full-blown solution implementation is engineered.
Prior to the solution implementation, 60 - 70 percent of specimens coming to the lab from
the nursing department were poorly labeled, meaning the barcodes were mis-aligned. Six
months after the task force committee went to work, the situation reversed itself. During
this study, “mis-aligned barcode label” was used as a pilot study to measure the
efficiency of the system in place. It was discovered that after the corrective program was
instituted, 70 –80 percent of specimens coming to the lab from the nursing department
had barcode labels correctly placed. The task force members agreed that if the current
mechanisms worked to reduce mis-aligned labels, similar mechanisms could work to reduce
most of the other specimen-collection errors.
Successful
implementation cannot be left to chances. Certain situations must be in place to allow
success to be attained unlike the circumstances of other studies being conducted across
the nation to reduce medical errors. In some of those studies, the key ingredients are
missing. Consequently, those studies are unable to attain and sustain positive outcome.
Our study is the first in the nation to break through those barriers to achieve and
sustain success. The crucial principles to help different institutions achieve success are
briefly discussed.
Successful
Strategies of Solution Implementation
1.
Give correct, and hopefully standardized information to staff members
regarding the process under question. For example, in a case where mistakes are being made
about how to operate a machine or how to perform a particular task or procedure, workers
must be given accurate information about such operations. Evidence from this study
indicates that workers do things wrong either because they have inadequate knowledge of
the process, are uninformed about the proper way to execute a process, are untrained about
the technical operation or are misinformed
by their peers. Many medical errors have been associated with the lack of understanding of
a procedure or equipment in use due to the complexity of the procedure for performing the
tasks. Errors also occur due to equipment failure as well. Implications of continuing the
old process as compared to the advantage of the new process should be clearly delineated
to the staff.
2. Redesign the process needed
along the process-line. In addition to correctly informing staff about the proper way to
perform a task and being sure workers are proficient to do the work, system design must be
evaluated. For example, in a particular hospital, many of the nursing staff members and
physicians were angry with the pharmacy department because of delay in processing orders.
Later it was discovered that the pharmacy was not only short-staffed, but efforts to
recruit more pharmacists had not been successful. Similarly, in a nursing department, many
wrong orders were being placed in computer by secretaries because the nurses were too busy
to double-check the orders. In both of these cases, a new process design was put in place
by both action-force committees working to solve the problems. In the first situation, a
request was made to a local school of pharmacy for interns to work at the hospital. The
problems were solved when more interns applied than were needed. They were used for more
technical work along the process of dispensing medications to different nursing stations.
The hospital loved the solution and decided to pay the interns stipends as they continued
their education and part-time work at the hospital. In the second situation, a designated
nurse was asked to check all orders being placed in the computer by the secretary before
any of the orders were executed. The hospital administration noted a lot of money was
saved by preventing many wrong and duplicate orders.
It should also be stressed here
that many of the old hospital computer systems were not designed with flexibility of
process redesign. The future of preventing medical errors must include the utilization of
the computer systems that are more malleable to process redesign to help create checks and
balances along the process-line to prevent errors.
3. Create a conducive
environment to foster correct implementation of solutions or process redesign with the
help of the hospital administration and the project master. In health care, we work in a
rigid environment where people do not like to change old procedures. Resistance to new
ideas is human nature because routine work does not take as much brain energy compared to
new unfamiliar procedures. It is therefore, very important to create an environment to
make the new ideas more attractive to workers. One way is for the administration to give
incentives to those workers making progress in correcting problems and preventing errors.
Another way is to relate the dangerous consequences of the old process leading to errors
and harming patients. Health-care workers should also be well informed about the
regulatory organizations’ requirements for such processes.
4. Engage in modifying
workers’ behavior to attain lasting receptiveness to new or modified processes.
Workers initial positive reactions to new or redesigned process may be temporary. To
attain lasting effects, workers’ behavior must be permanently modified to embrace the
new procedure. Otherwise, months down the line, the problem that was reduced at the
initial phase may return. The project master should also give the workers opportunities to
build the new procedure into their behavior repertoire. Modifying workers behavior may
involve a long-lasting campaign and continuous evaluation of responses and the effects of
the new implementation. Measuring of the sustainability of the positive outcome over a
period of time is crucial to evaluating the ongoing compliance after so many months from
the initial implementation.
5. Directly involve those who
work on the process-line in the process-redesign and solution implementation. Do not allow
any individual person to alter the design by a committee except if such an action is
against the hospital policy. Remember, the collective brainpower of a group of people (the
committee) is much bigger than that of an individual person. Hell-raisers are known for
trying to derail the progress of a committee. One of the shocking observations from this
study is the ineffectiveness of managers when given the task to implement new procedures
compared to when a similar task was given to those who work directly on the process-line
or with patients. Perhaps the failure of the managers was due to many factors: First,
their resistance to new ideas; second, their lack of receptiveness to external solutions;
third, their refusal to accept they had specimen collection problems; fourth, their lack
of willingness to share the new information with their coworkers; fifth, their inability
to find effective solutions even when they acknowledged they had problems; sixth, their
continuous war against the bearer (laboratory) of the bad news of systemic problems.
Failure of the task force to reduce medical errors when the group consisted mostly of
managers continued for almost four years. However, when those who work directly with the
process were the major components of the task force committee, in less than six months of
the campaign, substantial progress was made compared to the four years duration by the
managers for working on the same problems.
Immediate success was attained
party because those who work on the process-line know the problems causing the errors, the
implications of the problems and the work inconvenience caused by continuous problems.
While they attended the meetings, those working on the process-line rather than the
supervisors were able to effectively communicate the problems and solutions to their
peers. Also, working peers were able to place nonresistant pressure on their peers on the
process-line to follow the new protocol of process redesign. Positive interactions between
working peers allowed this to be attained. The result was a 70 to 80 percent reduction in
some specimen collection errors, improvement in the quality of patient care, and
substantial savings for the hospital.
6. Seek and retain the support
of the supervisors, managers and directors of various nursing units to help achieve
effective solution implementation. Although it was just mentioned that managers from
various nursing units did not work as well as task force members to fix the problems, they
remain a powerful and an integral part of forces needed to assure successful
implementation of the process redesign. These managers serve as police officers, watching
the progress of the process and new design. Their role in motivating and supporting the
process-line cannot be underestimated.
The success of this study is
never achieved by one person’s effort because a tree is not an island. It takes the
collective effort and support of the lab director and lab supervisors, nursing director
and nursing managers, and for the most part, workers between those two departments who
work cohesively to attain the success realized in this study. The process of working with
the workers between two interdependent departments is like connecting pipelines of a
networking system. Each time a project is designed along the process-line, there are
always backup plans in place just in case one pipeline connection is either temporarily
disconnected or unresponsive to initiatives. Working along those pipeline connections is
the only effective if the operation of the project master or the team leader is based on
the principles of diplomacy.
Sometimes lack of support
creates barriers for progress. In one of the institutions under study, despite repeated
problems from the emergency room and the intensive care units, the managers from these
nursing areas did not embrace the solution introduced by the laboratory. These two nursing
units targeted their solutions to those making errors, but the lab had a different program
that was more directed towards specimen collection errors. The task force committee
recommended that all nursing staff should attend the lab reupdating school in addition to
the information session created by these nursing units. Based on the problems seen on the
lab benches everybody especially those drawing blood needed to attend the lab 90 minute
reupdating school. But the nursing managers from these areas are not willingly embracing
the lab school. The lab was of the opinion that the lab’s reupdating school was more
detailed and able to stress the implications of medical errors more than was the nursing
exchange of information to their staff. Even the representatives from the emergency room
stressed that everybody in the house drawing blood must attend the lab school once a year.
Although the lab welcomed the nursing program to work with those making errors, such
programs in the past hardly worked efficiently enough to have a lasting and general impact
on the entire staff. Many other nursing units responded warmly to lab reupdating school
while the managers from the emergency room and intensive care units remained spectators on
the sidelines. Consequently, error reduction of mis-aligned specimen labels during a pilot
study was not as effective, particularly in the emergency room and intensive care compared
to other nursing stations. But the struggle continues for excellence in patient care.
7. Selecting the task force
members must be carefully done, based on those who are interested in solving problems
while working on the process-line. There are many good, hard-working employees who are
working on the process-line and are dedicated to improvement while others love to complain
till the world ends and are unwilling to work and fix the problems. Some workers also want
to enjoy the glamour of being committee members but are unwilling to do the work. They
therefore, leave the burden of more work on other committee members. Such nonproductive
members should be removed by a simple non-threatening procedure. For example, if a couple
of members are neither contributing their part to the progress of the committee or they
are being of deterrence, the team leader can temporarily dismantle the group. He or she
would give credits to everybody for what was achieved to that point and carve another
group with less members from the initial group, thereby eliminating non-productive
members. Not too many members will protest not being invited to a working dinner after the
end of a project. But many of them will protest being removed from the dinner table while
the project is in progress.
8. Identify strong,
dedicated and committed team leaders and project masters to achieve the objectives of the
task-force members. Based on what works, group leaders must receive adequate initial
training as team leaders to effectively direct the group. Being a team leader is like
being the captain of a boat with many, sometimes obnoxious sailors. There will be storms
along the way, and bad weather can occasionally besiege the journey. But the captain must
remain steadfast and fully committed. The team leaders must also know their limitations,
remain focused, keep the team together, create and retain the pipeline connection with the
hospital administration and keep the project in a positive direction. There are members
who will lose their motivation along the way. There are participants who may even become
nonproductive after a while, and there are others who have to be dragged along the way for
their occasional contribution. But the group leader must remain strong and committed,
despite all kinds of obstacles along the way of sailing the task force committee boat.
In life, there are leaders and
followers who dance to the tune of the same music. There are spectators and cheerleaders
who keep the events in motion. Sideliners are either confused or cannot make up their
minds, while the hell-raisers tend to disrupt the events as a call for attention.
Whichever place people may find themselves in life, it is not because the game tickets are
being sold, but because participants created their roles by the choices they made. From
the poem Dance of Life by the author of Overcoming the Invisible Crime.
9.Operational funding for the
program should be established by the hospital administration prior to the start of the
project. No matter how little it may cost, every task-force project will need some money
along the way. Money may be needed to buy refreshments for the members during meetings or
to pay those who are working more than their regular 40 hours a week. The most
embarrassing situation is for the hospital administration to be yelling due to overtime
from events conducted by group members. Sometimes the team leader is placed in an awkward
position when he or she requests petty cash for supplies or manage an event with
inadequate response from the hospital administration.
10. Success is achieve with a
project based on the abilities of the project managers, team leaders and their members to
coordinate and follow all the processes involved from the time of identifying the problems
to the time of solution implementation. It is simple to outline a process, and it is
difficult to follow the process through to completion. Occasionally, the team may get
off-line or be distracted or may even need to make a detour. Whatever the situation, the
team must get back on track to solving identified problems as defined by the initial
objectives from the beginning of the project. It is sometimes so easy to get off track or
to lose focus due to many challenges along the way. Success is also achieved and retained
by continuously monitoring the progress through subsequent report analysis. At any point
when a reduction in positive outcome is encountered months after the initial
implementation of solutions, it may be time to fire up the entire campaign all over again.
The entire strategies of solving problems through process redesign are not unique to
health care alone; they have successfully been used in other businesses as well.
This report is just a summary
of a long, tedious, and ongoing complicated processes to prevent or reduce medical errors
or to help redesign business processes to achieve positive outcome and better customer
satisfaction. For more detailed information of the entire process refer to the outline of
the in-house seminar presentation on pages 7 to 10. In reference to many interviews and
discussions with some health-care administrators across the nation, there is a
misconception that one person can be assigned the job to fix the problem of medical errors
for the entire institution. This is a fallacy! No one person can efficiently work along
the process-lines of many professionals and be able to fix all the problems at every
station along the process-lines. The failure of many processes to fix medical errors
across the nation is the erroneous reliance on one person as a fixer of all the problems
within the system. How can a pharmacist know more about a nurse’s job? How can a
nurse know more about a lab tech’s job? Can a physician know more about the process
of taking patients to surgery than the hospital transporters? Can a physician be as
efficient in passing medications to ten patients while being continuously distracted by
call-lights? The point is, everybody is an expert in his or her respective field or
process-line. Although most of the process-lines are interconnected during the process of
taking care of patients, those who work on a particular process-line, or along the stop
signs know how to redesign their work environment to make it more efficient.
The outline of in-house seminar
on page 7 may help every health-care institution to reduce medical errors, especially when
JCAHO is going to be converting to all unannounced inspections in a couple of years. This
is an end to dress-up rehearsals for many hospitals prior to inspections. Systems should,
therefore be implemented in every level of the health-care within the institution to
achieve an ongoing compliance with quality improvement. Establishing such an atmosphere of
ongoing compliance will take a couple of years through a powerful campaign within any
hospital. Consequently, it is of paramount importance to start the process redesign as
quickly as possible. This cost-effective in-house seminar gives the road maps, guidelines,
rules and tools with which individual health-care systems can efficiently construct safe
highways and stop-signs along the process-line of patient care.
Szamosi,
Diane, Phlebotomy Standards. Medical Laboratory Observer July, 2001.
Stay tuned for more progress report
visit: www.101waystopreventerrors.com
Progress report by
‘Yinka Vidal, Chair,
National Campaign to Prevent Medical Errors
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