Human Error: Does not exist

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

Co-authors

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

©M HEMADRI 

Follow me on twitter @HemadriTweets

My mini e-book 'Standardised Management Conversation' is available - click http://www.amazon.co.uk/Standardised-Management-Conversation-Hemadri-ebook/dp/B018AWBJTU 
till 31 December 2016 all my earnings from the sale of this book will be donated to charity  http://successinhealthcare.blogspot.co.uk/2015/11/standardised-management-conversation.html

 

Fearless Healthcare is what we want

Recently read a book called 'Driving Fear Out Of The Workplace' by Kathleen D Ryan and Daniel K Oestreich. It was published in 1991 so obviously you can see that my wisdom is only now dawning. It is based on the 8th principle of Deming which is 'Drive fear out: employees must not be afraid to ask questions or take a position'. The book is written in an easy language and narrative style with enormous number of quotes gathered from their work with a variety of organisations but when read reflectively it can have profound impact on us and others.

The book wants us to
- be able to discuss the undiscussables
- realise behaviours that create fear
- understand the cycle of mistrust and break it
- acknowledge the presence of fear
- value criticism & reward the messenger
- reduce ambiguous behaviour
- move from participation to collaboration
- challenge worst-case thinking

The authors believe that driving fear out will overcome the invisible barriers to quality, productivity and innovation. The book is nothing to do directly with healthcare and has no direct examples but at a human level the threads are common. I recommend the book.




Healthcare & Fear

There are many reasons that driving out fear is even more important in healthcare. The very strong hierarchical structures in healthcare is an ideal culture medium for fear to thrive especially amongst the medical and nursing colleagues. The mostly pick and mix nature of evidence in healthcare delivery makes these hierarchical voices even more powerful. The difficulty with evidence generally creates poor systems, people who work within poor systems understandably do not do well and the culture of defensiveness and fear becomes greater.

Establishment is very strong in healthcare, in the UK clinical practice context you must submit to the clinical establishment (royal colleges, specialist bodies, et al) or to the research establishment (universities, funders) or face difficult consequences. Clinicians have a legal obligation to provide care recommended by NICE 'guidelines', there are armies of back office people who audit compliance to NICE guidelines which everyone fears of falling short. Providing the treatment recommended by NICE is a statutory duty i.e. law, I wonder why it is not called law and then define some exclusions. Why the euphemism? Now, would you have a fear of falling foul of a law?

The current economy does not help with many reduction in posts and changes in roles. It is also well known that in the context of the NHS the reorganisations are almost continuous and many non-doctor staff do live in fear of the next change that may adversely affect their role, skill and income.

Generally high anxiety and stress is understandably common for clinical professionals when dealing with patients given the very high emotional component involved in any healthcare advice or treatment especially acute care. The stress levels are even higher for patients and that is projected on to clinicians and reflects. This puts pressure to get it right every time, there is a fear amongst clinicians about getting it wrong; get it wrong in high finance and few points might drop of the footsie index, getting it wrong in healthcare could cost people a hand or a foot literally. But working with fear does not help the cause.

Constant comparisons with other industries (aviation, manufacturing, etc) while is very important for healthcare professionals who can understand the principles behind these comparisons and use them for improvement, is often taken out of context and has created an atmosphere where some of the public begin to have very high expectations that are difficult to service and some of the pubic fears healthcare. When let down, these lead to potential litigation which is a common fear amongst clinicians.

I could go on, but you get the idea. I do believe that fear should be driven out of the work place and especially so in healthcare; it would liberate the true power and potential of clinical professionals.

Fear could result in some of the effects discussed earlier in the blog, such as branding people as bad apples (http://successinhealthcare.blogspot.in/2012/07/bad-apple-theory-in-healthcare.html) or agreeing with persons so as to please them as in the Abilene Paradox and other not so helpful behaviours. In healthcare, these combined with the issues around evidence and process efficiency leads to the phenomenon of Clinical Wrongology.

What are your fears at work? What are its effects? How do you and your workplace deal with it?

©M HEMADRI 

Follow me on twitter @HemadriTweets