Medical Errors Report #2

A Four-Years Solution Implementation Study

45 Highlights of Fixing Medical Errors and Systemic Failures

 This book is the chronicle of those management crises encountered during this observational study. Before telling the story of these encounters, it is important to first outline the summary of the problems and solutions that took place in the past four years of this study. This is the only study so far discussing in details why the initiatives for fix medical errors are failing.

 Slow Progress Persists in Fixing Medical Errors

In the four years following the Institute of Medicine’s report of December 1999, progress in reducing medical errors, despite all enthusiastic effort has been very slow or in some situations, non-existent. The reason for this slow progress is based on multifactorial issues many of these are discussed throughout this report. Dr. Donald M. Berwick, the President and CEO of the Institute for Healthcare Improvement, explains in his article, “Invisible Injuries” (Washington Post, Tuesday, July 29, 2003) that despite the response to the IOM report of 1999, there is no evidence that health care is safer in the United States. He states that our health-care system is blind to patient injury, and that one of the keys to fixing medical errors is to find a way to make patient injury more visible, even to hospital executives.

 Many hospital administrations are under the illusion that if they put together what they term a multi-pronged approach, or many different solution strategies, medical errors will automatically disappear. This is a great fallacy as demonstrated by the results of this study. Putting all sorts of programs together does not guarantee positive results. Such a fallacy was clearly expressed by Calvin M. Pierson, the president of the Maryland Hospital Association, in his response to a Washington Post article of December 9, 2002, about the scandalously slow progress towards reducing medical errors. Most of us in health-care are disappointed about the sensationalism of medical errors in the media that do not include stories about solution interventions or reasons for lack of progress. This Washington Post report is more beneficial to the health-care industry because it challenges health-care administrators all over the nation to reevaluate their solution strategies to reduce medical errors.

 In his response article, Calvin Pierson alludes to the point that Maryland is doing much better than other states regarding medical error reduction. He outlines a litany of strategies put in place to improve quality of care. He refers to the installation of a multi-million-dollar drug prescription technology, establishment of a no-fault error reporting system, collaboration with the Institute for Safe Medications Practices, and so on. There is no doubt that some of these strategies may be helpful in reducing medical errors, but Pierson does not mention any data from this solution implementation in his article.  This point cannot be over emphasized, just because many solution strategies are put in place does not mean they are working to reduce medical errors. Results must be measured over time. Positive outcome should be identified from the result as a trend. Sustainability of the positive outcome should be observed. Measuring the outcome over a period of a year is recommended to ensure that the positive outcome is sustained over a long period of time. At the time the positive outcome starts to diminish, it is the time to re-energize the campaign all over. Quality improvement cannot survive with a shot-gun approach; it has to be an ongoing and sustained effort.

 Patrice Spath’s online article “Improving Quality with Systemic Thinking,” (RHIT Brown-Spath Associates. Forest Groves, OR., Dec. 2002) points out that just because each part of the system is performing as expected does not mean the overall system will perform as expected. She stresses that any intervention that does not alter people’s thinking will produce no change.

 During our study, the same issue was encountered in one of the New York hospitals under study. For four years, this particular hospital instituted many strategies to reduce specimen collection errors. Nursing staff members were given annual up-to-date information about specimen collection errors, and display boards were designed and placed in nursing stations all over the hospital. A newsletter was created to notify nursing staff about updates in specimen collection errors. The hospital laboratory created a lab school to update those who made errors. Despite all these strategies, which took place over four years, the rate of errors will go down after some form of intervention like the nursing Blitz days and only to rise a couple of months later. Later, some of the committee members asked the group to look at what might be going on since the solution implementation did not achieve a sustained reduction in errors.

A few possible explanations for the lack of reduction of errors were discovered. First, there were too many nursing staff members close to 500 drawing blood. Specimen collection errors are very low in hospitals using well-trained phlebotomists (10 –20) to draw blood. Effective training resulting in better compliance is achieved when less people are drawing blood compared to when 500 people are drawing blood. Second, many of the nursing staff drawing blood were never properly trained in the procedure.  Most of them learned on the job. Consequently, they were never educated about the precautions involved. Third, many of the nursing staff members did not want to draw blood. It was an added burden and extra work they would have liked to do without. Fourth, the idea called multi-tasking of removing phlebotomy from a well-trained laboratory staff and giving it to an under-trained nursing staff was an ill-advised solution strategy. This same solution has failed in many hospitals across the nation. Most of the hospitals that had introduced this idea now lament doing so due to the large number of specimen collection errors and the increased chance of patient harm. Fifth, the management style of the hospital administration had demoralized employees to the point of mental paralysis leading to impotence of action. The saddest part was the lack of the administration’s awareness of the detrimental effects of its management style on employee morale. When any administration is besieged with the hyper-emotions of ego-driven managers in search of constant self-gratification, little can be accomplished in fixing systemic failures.

 Again, Patrice Spath’s (2002) article points out that demoralization of project staff is a frequent and costly consequence of failure. People’s actions are easily influenced by the structure of the system in which they work. She stresses that if the system makes it hard to provide outstanding customer service, no amount of training will change employees’ behavior.