TO ERR IS HUMAN; TO LEARN FROM THEM ESSENTIAL


In the movie “It’s a Wonderful Life,” George Bailey saved pharmacist Gower from mixing poison into a prescription.  Gower’s son had recently died from influenza, and Gower was thinking of his son, not the prescription.  Here’s the root cause analysis.  Why was poison there?  Because it always had been.  Why had it always had been?  The movie doesn’t tell us.  Why didn’t Gower notice it was poison?  Because he was still grieving his son’s death.  Why was he working?  Because he had to.  He had no choice.  Why had he no choice?  Because you worked or starved back then.  Why?  Because we had no safety nets.  Why not?  Because it had always been that way. Why?  I don’t know.  End of analysis.

Did Gower want to err?  Of course not. But he almost did.  Poison has always been present in pharmacies.  It’s called the wrong drug, the wrong dosage, or an unexpected interaction. None of us is immune from making errors.  “Be more careful” isn’t the solution.  We need systems robust enough to make errors impossible, for people may be preoccupied, sleep-deprived, hurried, interrupted, multi-tasking, under pressure to produce may all combine to produce errors. None of us is immune.  “Be more careful” isn’t the solution.

Compare how improvement doesn’t and does occur, respectively.   I once got a letter from the quality committee castigating me, because a nurse asked me, a consultant, if she could have an order to get a blood gas analysis.  I gave the order, the blood gas was mildly abnormal, and I neither got a call nor followed up on the result, which was wrong.  I felt worthless, a bad doctor.  Good doctors are perfect, and I wasn’t perfect.  Nobody asked why these results didn’t go to the attending physician, or weren’t even called to me.  Indeed, the idea of quality in medicine was to assign responsibility and blame.  It was my job to follow up on this blood gas, and I failed.  Don’t do it again.  You are reported.  What did I do after that?  I never ordered another blood gas as a consultant again.  Was that optimal care? Nope.  But I wasn’t going to be nailed again for not doing what the attending should have.

Here’s an example of how root cause analysis helps.  The columns on the Lincoln Memorial were eroding from power washings, and this was becoming a concern.  Rather than just replacing the marble, very expensive, somebody actually talked to the people doing the work, an amazing idea, since while management traditionally makes decisions, the people on the ground really know what is happening.  Asking why learned of frequent power washings, which came from bird poop.  Why?  Birds came to eat insects.  Why?  Because insects were attracted by floodlights.  Solution?  Shine the lights, not for two hours after sunset, but only for 30 minutes, which didn’t attract insects.

Oregon is the only state where pharmacies are included in the confidential error reporting system.  I was disappointed to learn how few errors are reported here with a full “root cause” analysis. The first pharmaceutical report was in 2012, a few years after the program began.  Of 200 total reports, only 28 were last year among 721 pharmacies state-wide.  I’m a retired physician, I take medications, and I have considerable knowledge of medical errors, having been on both sides of the error divide.  I regret my errors, but what has additionally bothered me was that I could neither unburden myself of my guilt nor could I allow anybody to learn from them.  Silence does not improve systems; it allows the same error to recur.

Thinking on one hand I might have something to offer, despite my age, I contacted the Commission, whose staff were most kind to meet with me.  I wasn’t seeking employment, hoping only that my passion for improving medical quality and safety might allow me to contribute.  I am willing to help in any possible way at any interested pharmacy or health care facility in the state.  Reiterate. No charge, free.  Every person in my small family has suffered from medical errors.  This isn’t surprising.  Nor would I be surprised if every pharmacist who reads this knows that he or she has made errors or had close calls.  And didn’t report them. Shame, fear of reprisal, no time, no harm no foul. Which one?

I was wrong about numbers of reports.  I expected that was crucial.  It is not.  Pennsylvania has a quarter million reports annually, but “fall” without knowing why doesn’t help, not even if you knew the numbers state-wide.  How do I know?  I asked that question.  A few thoroughly investigated reports, learning why something happened until the question can no longer be answered is effective.  The Commission has people who can and want to help with this. I could, too. However, the culture of medicine and management must also change, away from punishment, excuses, fear, shame, ridicule, silence and hiding, to one of openness, learning, sharing information and power, the goal being to improve systems to cause less harm.  I am pleased that the Commission has done so much.  I am disappointed that 14 years after I proposed a similar program, how far we still have to go.

Were each pharmacy to perform one thorough analysis on a mistake every other year, this volume would have vast potential to improve systems that currently hurt patients and shame those who make errors.  The information could be shared state-wide.  Far from desiring to punish well-intentioned, hard-working people, I want them and others to learn from errors or near misses.  We make mistakes.  The days of hiding them must end.  Top management must vigorously support reporting by encouraging front line people to talk candidly to the Commission about what happened, with absolutely no fear of reprisal.  That’s a tall order.  I do not want to hear about percentages of successes, because counts of serious mistakes must be driven to zero.  In 2001, 99.999996% of all domestic flights were safe, and I doubt anybody believes that was a good percentage.  One mistake that is investigated is not going to cause long waits in Eugene, Portland or Bend.  Mistakes are made.  That is a fact.  We need to understand thoroughly why they occur and how to prevent them.  “Double check” and “education” don’t cut it.  We don’t tell people to put their foot on the brake when they back the car.  Cars are designed so that people can’t shift into reverse before their foot is on the brake.  Repeating “we believe in safety” does not establish validity.  “You mean you once didn’t?” I want to reply.

For reporting the error, George Bailey was initially slapped on his bad ear by pharmacist Gower, who later embraced George, when he realized the scope of his error.  It’s time to end both the slapping and the fear of it.

For reporting an error, George Bailey was initially slapped on his bad ear by pharmacist Gower, who later embraced George, when he discovered the error.  It’s time to end both the slapping and the fear of it.

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