Human Error. Does it really exist?
We have discussed wrong site surgery/procedure (http://successinhealthcare.blogspot.co.uk/2012/10/mark-site-campaign.html)
The equivalent for this in histopathology would probably be labeling errors. Labeling errors could at the best lead to rework/reprocess and at the worst result in wrong report with potentially catastrophic effects on patients which can be as grim as wrong site surgery. In most laboratories there are multiple checking steps within the process to detect errors and prevent them leading to errors in reports that could harm patients. In a busy pathology laboratory in England in 2007 there were 113 slide and block labeling errors. By 2009 after a series of Kaizen events it dropped down to just 2 labeling errors which would be a 98% improvement giving a short term six sigma score of 5.8.
What is interesting are the results of the root cause analysis of the 113 pre-Kaizen. Most of them showed that human error as one of the root causes. What is remarkable was the post-Kaizen improvement was achieved with the same people. The root cause analysis of the 2 post-Kaizen errors showed further opportunities for system improvement.
If system improvement can reduce or eliminate (well, nearly eliminate in this example) human errors, the immediate logical obvious question to ask is 'Does human error exist?'
Deming says that 80% of quality problems are caused by management and 20% by employees. It is further thought that since the employees are essentially a part of a system for which the management is responsible, almost all quality problems are caused by management. Deming seems to have taken the view that the focus and emphasis on quality has to be top down and the creation and delivery of quality should be bottom up.
There are a number of areas where zero errors or quality problems (or virtually zero errors) are possible. In the same pathology lab the number of endoscopic biopsy request clarifications (which used to happen due to doctors illegible handwriting) are now down to zero since the lab started asking for a copy of the printed endoscopy report to accompany the specimen. Previously it was thought that poor handwriting and not putting enough information was a part of human error due to human fallibility, in practice it caused arguments, distress and wasted time.
We are now beginning to question whether there is anything called human error at all. As realists and practical professionals we realise that there will be some areas where perhaps human error does exist and possibly cannot be avoided but we believe that for people working within well organised systems this should be a rare thing. We wonder if people with poor training and no experience in quality methods who nonetheless think they are capable of understanding quality improvement are unable to analyse with an aim of system improvement and hence blame human error as a reason by default. After all everyone has recognition and sympathy for the phrase 'to err is human'
We are having an emerging view that 'Human Error' as an attribution for quality problems is a cop out clause used by poor managers and weak leadership. It need not be so. However it requires managers and leaders to shoulder the responsibility for building continuous quality improvement into their work and the way their teams function. CQI systems are already available and they have to be applied with patience and persistence - those who do that will find the path of continuous improvement and will eventually share this view of ours that 'Human Errors does not exist in organised systems' though it may sound very radical right now.
M Hemadri & David Clark
David Clark is a Consultant Pathologist and National Clinical Lead, NHS Improvement. David's thoughts expressed in this blog post are his own personal views.
PS: Regular readers of this blog would have read a previous post about how we find designs which set us up for failure (not deliberately) and we then blame it on 'human error' http://successinhealthcare.blogspot.co.uk/2012/12/blame-it-on-human-error.html
Follow me on twitter @HemadriTweets