Medical Errors Report #15
A Four-Year Solution Implementation Study
A Swiss-Cheese Model Does not Create Medical Errors
Contrary to what many people have said, medical errors are not created by big holes in the system resembling the Swiss cheese model. If the holes in the health-care system are that big, patients would be dying right and left, and a few would be alive today. Based on what we have seen to date in this study, most medical errors are created by simple systemic failures. Forgetting to ask a patients name before blood transfusion is not a complicated problem even though the result is tragic. Giving the wrong medication because a nurse entered the wrong room is not a complex issue even with disastrous outcome. These situations are not giant puzzles to dismantle. The process of fixing errors is, however complicated by many systemic failures, administrative problems within the health-care administrations, and most importantly, due to human resistance to change.
Lack of Effective Utilization of Employees Time Costs Institutions Money
In various hospitals, uneven distribution of work among employees in the same department allows the burden of heavy workload to fall on a few hard-working employees. This type of set-up is common in laboratory, x-ray, nursing, and pharmacy departments, etc. When a few employees are carrying a larger workload, the quality of work is poor; operational cost is high and the danger of deadly errors is also very high. When a group of employees would rather play than help their busy peers, work is not distributed evenly and those with a heavy workload, in a hurry to complete the work are prone to make deadly mistakes.
Indecisiveness Reduces Effective Implementation of Solutions
At a point and time, indecisiveness was a major problem because some members within a problem-solving group were unable to make up their minds about how to approach an issue. Even after a committee makes a decision, members sometimes change their minds after hearing negative comments from their peers or when they think other employees will blame them. A particular lady in one of the committees used to change her mind based on what different people were saying. Each time she talked to anybody within or outside of the group with a different opinion, she would change her mind. In one case, the director of nursing made a team to redesign a display board three times because the director kept changing her mind about what she wanted on the board. The incident created frustration for some of the committee members. Unnecessary repetition of work waste time and money.