Business language in a public service NHS is wrong

One of the first things to get right in the NHS is the language. Perhaps the use of wrong language is the expression of some fundamental misunderstanding of the way the NHS works.

First thing to understand is that the NHS is not a business. It is a publicly funded and mostly publicly delivered service. So the NHS has to stop using the terms and language of business.

Let us look at the terms profit and loss. Why would the NHS use those terms? The terms to use are surplus and deficit. NHS uses things like trading account, when it actually does not trade in anything. NHS staff including clinical staff in their ‘management’ courses are taught how to write a business plan. Why? Why should people in an organisation that is actually not doing business know or write a business plan? They should be writing a service development or service improvement plan which is totally different from a business plan. The aim of a business plan is to generate a profit. The aim of a service development or service improvement plan is self-explanatory. A primary aim of business is to be profitable – get a return on investment. A secondary aim of a public service healthcare organisation is to stay within budget.

A private company’s money is from its sales, the NHS does not sell anything, NHS money is derived from a budget. Technically when sales generate more money than how much the product or service costs then the private company makes a profit and in theory the profits are unlimited. The NHS money is from an allocated budget, if less money than the allocated budget is spent then a surplus is generated – by definition the surplus is limited, very limited.

When a private company sells less or at a price less than what it takes them to make the product or deliver the service then the company makes a loss. By definition this loss is limited to the capital of the company (for limited companies). When the NHS spends more money than its allocated budget then a deficit (not a loss) happens, this money is spent for keeping the health of the population and hence in theory it is unlimited (as a public funded service the government can print money) though in practice a line will be drawn somewhere when the service is delivered differently, perhaps inadequately.

For a private company the theoretical profits are unlimited and for a public service like the NHS the theoretical surplus is limited. For a private company the losses are limited and for a public service like the NHS the deficit in theory can be unlimited. Some NHS managers many not know or understand this, many do – yet the language of profit and loss are used. Wrong language leads to wrong attitudes and wrong expressions.

Sales for a private company can be very variable from day to day, week to week, month to month, yet to year. Budgets vary too but not that much. In fact budgets are assured though the amount can vary. Every NHS clinical organisation can be assured that they will get some budgeted amount next year, simply because their catchment population’s need remain, irrespective of what the organisation is called, how it is structured or who runs it.

The fundamentals are different between a business and government organisation. The reasons, attitudes are different, the methods are different, the language should be different. Yet the business language is used in the NHS. When a business language is used, business attitudes kick in. When a public service is run like a business yet the funding/accounting principles are different people do not know where to stop. People think by making a surplus they are getting bigger and better, they often do not. People by not calling it a deficit and not call it a loss when they make a loss and yet they do not really go out of ‘business’ or ‘existence’ they do not realise when to stop. The ability to recognise a good or a bad idea gets distorted at the best or lost. That is exactly what has happened to NHS managers – wrong language leading to wrong thinking leading to an inability to recognise good, bad, right, wrong. It is like a hypoxic pilot in free fall.

Let us get the language right. The language influences understanding which impacts on attitudes. Get the language wrong and the path towards disaster is established with the inability to recognise it till it is too late.

©M HEMADRI

Follow me on Twitter @HemadriTweets

MSc in Healthcare Improvement Leadership

Applications are now open for the second cohort of the MSc in Healthcare Improvement Leadership starting in October 2015.  This is a bespoke programme that has been developed jointly between University of Hull (Faculty of Health Sciences) Hull University Business School and Hull and East Yorkshire Hospitals and is open to all Healthcare Professionals.  

The first cohort (a mixture of clinical and non-clinical staff) have reported that the programme is “interesting, enjoyable and thought-provoking” as well as “blowing my mind with different perspectives of quality”

If you are interested in being a part of the second cohort and for further information please contact:-

Tracey Heath – Director of Enterprise

University of Hull

T.N.Heath@hull.ac.uk 01482464519

Further information:

MSc in Healthcare Improvement Leadership

A unique opportunity has arisen to undertake a Masters in Healthcare Improvement
Leadership at Hull University. This MSc programme is developed jointly between Hull
University, Hull Business School and Hull and East Yorkshire NHS Trust. This programme is
open to all healthcare professionals from primary, secondary and other health care sectors.

Aims

- To provide the participants with theoretical and practical understanding of the
concepts of quality improvement in healthcare delivery

- To equip the participants with practical tools to enable quality improvement

- To equip the participants with the attitude and ability to be a leader of healthcare
quality improvement

Objectives

- To explore the links between evidence, experts, experience, policy and practice.

- To understand the relationship between quality and cost

- To understand the concepts of shared baselines, local clinical protocols and the
improvement method

- To understand the modelling of the process of quality improvement

- To review tools available for healthcare delivery improvement

- To understand the relevance of measurement in improvement and to learn about
the tools to do so

- To understand the various kinds of leadership that brings about the preferred
response from colleagues using a selection of human factors and communication
methods thus defining the human face of quality improvement leadership

- To appreciate the importance of learning from immediate peers and colleagues.

Attendance Requirement
There will be 10 contact classes in the first year which participants are required to attend.
Other aspects of the course will be delivered by a combination of e-learning and support as
needed.

Modular progression
At the successful completion of first year there will be the option to take the qualification of
Certificate in Healthcare Improvement Leadership and to progress to a Diploma and Masters

©M HEMADRI

Follow me on Twitter @HemadriTweets

 

Declaration of interest: I teach some parts of the course. No current financial interest.

Power words to avoid in healthcare

On words such as 'intelligence', 'insight' and 'discretion' used as tools in demonstrating power.........................

A colleague had an email from a clinical director asking to ‘acknowledge that CT Cologram is a scarce resource to be used intelligently’.

When we got talking about this we wondered how one was supposed to respond, react or put this into action. What did that mean? Does it mean that they as a department they were using the resource like a bunch of idiots? Is this saying that they were a part of a group of people with not such a high intelligence? They were talking about doctors most of whom had at least two degrees and many years of training and experience - generally thought of as abundant proof of intelligence.

You can see this has raised my hackles. What is really interesting is this comes from a hospital which had one of the highest utilisation of CT scans in the country. If they were abusing CT facilities already, why would a cologram (colonography) be an exception? 

The issue is not the CT use intelligent or otherwise. The issue is the lack of understanding of how clinical management works and the use of operational management language. It is the lack of analysis and lack of definition behind these statements that are the problem. Of course no manager who imagines he/she is worth his/her salt will ever agree that this type of communication is grossly deficient. In fact the managers will insist that ‘intelligent use of resources’ is essential. And they can prove it. They will prove it by letting others use the resource and then using their higher hierarchical authority by making a post-event, ad hoc individual judgement on others who used the resource intelligently. You can see how it massages the ego of individual managers and riles up everyone else.

There are many other terms which lack analysis or definition yet used very liberally by everyone. Insight is one. Discretion is another.

Many doctors in trouble are accused of lack of insight. A GMC related official described insight as breathtaking arrogance in the face of overwhelming evidence.....  So, it is safe to assume that when evidence is presented to a doctor that he/she is no good and yet the doctor maintains that he/she was good would probably classed as lack of insight. At this point, it may look acceptable.

The point is, the use of ‘lack of insight’ as a reason and sanctions that follow often comes from a people with higher authority and directed against people with lower authority. In medical practice there is none or very little evidence for many things we do. In such a situation evidence becomes the view of a group of people in power who are then not inclined to look at the evidence presented by the weaker party. Insight becomes a power game. 

Let us look at discretion. Let us say that your boss in clinical medicine says that all patients are not the same and you must use your discretion according to the given situation. You are likely to think that your boss has given you a lot of freedom. What you are actually being set up for is another power game where your boss retains the right to question your discretion, pitch your discretion with others discretion and to override your discretion. Now you might think that is why you have bosses. But what actually happens is a clear recipe for failure and conflict. 

There are better ways of dealing with these. At a simple level as a starting point is to stop using such words which have the potential to confuse and cause harm; words such as discretion, insight and intelligence in day to day operational activity. I am not saying these words or their implications are not important, of course they are; I am questioning if they should be used in day to day operational management especially in healthcare. 

Instead clear definitions agreed as a group, in the form of specific and detailed protocols with further second and third order protocols defined when the first one does not fit might be a better way in operational management in healthcare. There will be a situation when these definitions will not work in which case a variation made after very quick group consultation which is then analysed later may be needed.

The main issues are that you will not like this since you might feel your autonomy is being reduced; your boss won’t like it since he/she may feel that his/her power is being reduced. Finally the chances are you, your colleagues and your boss will not agree on most things at an operational level; well you see this is not your fault as clinicians are taught only how to make individual decisions implemented according to a power based hierarchical scale. 


Clinicians have never been taught on how agreements are reached and never experienced the power of agreements between them.

There are clear ways to achieve this. That is when you will find Success in Healthcare.

©M HEMADRI

Follow me on Twitter @HemadriTweets

PS: If you would like to get away from the conventional use of terms such as discretion, insight, intelligence and move to a different approach; if you would like to know what agreement actually means and would like help to achieve it – you are welcome to get in touch with me mr.hemadri at gmail dot com

Healthcare has no Red Teams - we need them

NHS has no red teams - we need them

Defence forces have red teams. The US defence has had red teams since the early 2000s, soon the UK defence forces followed with their own version with slight variation. A few private companies such as IBM use red teams.

An internet search did not reveal healthcare especially the NHS using Red Teams.

What is Red Team?

A red team is an 'independent' team within an organisation that is deliberately created by the organisation  to critically analyse from a variety of perspectives (especially from an opponent or competitors perspective) and challenge the organisations' strategies, assumptions, operations  and all other aspects with a view to helping the operational part of the organisation get to a better position.

Basically you hire and pay a team of people to stuff you so that when you get out in the big bad world you don't get stuffed real time.

Red Team is something  but not fully like the opposition in the parliament whose job is to oppose the ruling party yet work for the benefit of the country. The opposition in the parliament provides an alternate view of the issue in question which the government must consider but need not necessarily act upon. A good government would willingly adopt the opposition's ideas if it would benefit the country. Of course given the unsavory political overtones and entrenched positions of political parties these days, this may not be the best example in practice but I think you get the gist. A red team in your organisation is a paid opposition without the baggage of politics - the ability to thoroughly analyse and provide an alternative point of view to the powers that be but no inherent ability to act on their own views.

A Red Team is not................

Red Team is not about providing innovation or offering solutions. Red Teaming is not strategy formulation by the management or organisation. Red Teaming process runs either in parallel to the strategy formulation or immediately after the strategy formulation but before it is finalised, signed off for implementation.

Red Team is not made up of union reps, protestors, resistors, laggards, innovators, management cronies, enthusiasts and so on. Red team is not a group with representatives from any area. Red Teams are not the same as whistle-blowers. They are certainly not people from 'risk', 'clinical governance' or any other over used cliched terms. They are not part of management or operations.

Executives are not obliged to follow the red team's advice or recommendations; they are only obliged to listen carefully and consider if they are suitable for implementation. Post-implementation, executives will be obliged to review their operations in the light of the prior recommendations of the red teams so that better learning can happen and be captured for future operations. The red team does not do operations, it is not the boss. The executives are responsible for the operations and results. The red team provides feedback, reflections but has no power to implement, reward or punish. Red team never says 'I told you so' irrespective of whether things have gone right or wrong; they take no credit or flak for success or failure of operations - that belongs purely to the executives.

Red Teaming

Red Teaming are a large set of tools and techniques that take time to learn, taught to people with prior operational experience and high level of maturity. Red Teams are friends who are playing the role of the enemy. Red Teams will face resistance and hostility. Red Teams are people who will pick holes in your plans and shred your strategy during the day and yet party with you in the night. Their level of development is such that they will have to think and act like the enemy, be the enemy so that they can help their friends. Red Teams often do not have automatic rights on most things, they will have to engage and negotiate at every turn. They have to be nice to you to you before you will consider their help in tearing down your own plans - see the complexity in human interactions here? Red Team exists to falsify the organisations' and its executives' theory.

It is important to remember that Red Teams and Red Teaming is not 'process driven', it has been described as an art, something to help with intuitive decision making. To convert them into 'tick boxing' so that we can claim we have a Red Team who have done the Red Teaming is very tempting so that operations staff can move on with carrying out their high pressure functions on a day to day basis but would be an expensive same side goal.

Healthcare needs Red Teams

Essentially, one of the fundamentals of the army is the business of protecting lives and minimising loss of life; like healthcare I suppose. Evidence based healthcare has huge problems and still in its infancy. Even if enough good evidence was available the complexity of healthcare means that the decisions will still be very different from many other industries. While other industries will need Red Teaming to look at from the competition's perspective, healthcare especially the NHS, needs Red Teams to look at itself. That will be an even more specialised art. We need that art and those artists urgently.

Do we in healthcare have the guts or the maturity to have red teams?

© HEMADRI

Follow me on twitter @HemadriTweets

Further reading

UK version of Red Team https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/142533/20130301_red_teaming_ed2.pdf

US version of Red Team http://usacac.army.mil/cac2/UFMCS/Repository/RT_Handbook_v6.pdf

Skin in the Game

DO DOCTORS AND NHS MANAGERS HAVE ENOUGH SKIN IN THE GAME?

Skin in the game is a term mainly used in the financial world where it is thought that those persons who are playing the game (e.g. fund managers) should have their own money and reputation involved so that they are as rewarded or as damaged as the people on whose behalf they play the game (i.e. their customers, investors). Philosopher and author Taleb has ignited a debate on the importance of this, he points to a Hammurabic code where if a house were to collapse and kill the owner of the house then the builder will be given the death penalty - now that is some real skin. This blog has already written on how Warren Buffet would not take a fee unless he crossed a certain level of achievement for his investors (http://successinhealthcare.blogspot.co.uk/2012/01/getting-paid-for-performance-buffet.html); apparently Buffet also has his own money invested along with his investors - he has enough skin in the game.

This got me thinking on what kind of 'skin in the game' we have in the NHS. Of course that is a large one to put out in a short blog. Lets try a limited short version.

In the past when doctors were employed as consultants in the NHS there was a requirement to live within a defined distance of their hospital so that they can respond to urgent and emergency calls when they are on duty and also help their colleagues when necessary even if they were not on duty. In the past consultants had an obligation to let the hospital know if they will be out of the area (even if they were not on call or on annual leave). Doctors were paid some money as relocation expenses to facilitate the same.

This obviously meant that the doctors working in a hospital lived within the catchment area of the hospital. In the event of an urgent need for healthcare for the doctor or for their families, they are highly likely to attend the hospital where they work. The success and failure of the hospital had the potential to directly affect them. In the last decade or so, the obligation to live within the local area seems to have disappeared due to a combination of societal changes of both spouses working and the officialdom seeming to demand that the doctor be available only when rostered to do so. However a large number of permanent senior doctors still live in the catchment area of their local hospitals. By definition there is skin in the game - if your hospital mortality or morbidity or general services were bad you and your family were likely to be affected by it.

The other aspect for consultants in the NHS is many consultants expected to work for many decades in one hospital, they do not expect to move. This has seen a slight change recently but it is substantially true that you would generally not find NHS substantive consultant post holders move very often. They develop, grow skin into the game. There is of course the issue of excess skin in the game where people with too much stake take too much risk, perhaps in the case of NHS consultants it may be a case where due to their superior knowledge of local and national situation they learn to avoid personal risk while all the risks remain for their patients. The doctors have a reputation risk - this is really serious - so serious that a doctor can be struck of for damaging the risk of their profession; at a personal level the reputation is equally serious;  due to peer pressure and long service reputational damage can be devastating.

I am unable to find a historic or current requirement that states that executive directors of NHS hospitals were/are obliged to live in the catchment area of their hospitals. I know of many hospital directors who do not live in the geography covered by their local hospital. This means in reality they have not much skin the game. In contrast to NHS consultants, board directors stay in post only for a fraction of the time that a consultant stays in post - compared to consultant appointments, executive director appointments are practically musical chairs or passing the parcel. Again there is not much skin the game. Of course there is a reputational issue but with performance measurement in the NHS for managers not being so accurate as say for a financial fund manager a large gooey fudge substitutes for reputation.

I don't know how practically applicable the above thoughts are. I have already written about the fact that NHS board director contracts have no reward or punishment for anything other than financial performance (Whose job is it to reduce mortality? http://successinhealthcare.blogspot.co.uk/2013/06/whose-job-is-it-in-nhs-to-reduce-deaths.html) Modern life and employment conditions may mean that we may not be able to demand that people live where they work. However we do need to find a way to ensure the skin in the game for NHS managers and directors; increase skin in the game for doctors.

Perhaps a starting point might be to publicly declare if they live within the area of the hospital where they work and how long have they lived within the area (not asking for private addresses, just for HR to declare if they live within the area). Perhaps remuneration and penalties should be linked to quality of performance (when we get around to understanding how we can measure quality meaningfully). We must think of other ways that suit the modern world to increase skin in the game. Healthcare is person to person business, very important for healthcare professionals to remember - no skin means poor game.

©M HEMADRI 

Follow me on twitter @HemadriTweets

'Nakamura invented the light bulb'

Would Nakamura invented the light bulb if he was working in the NHS?

Nakamura invented the light bulb, that is what we might probably say one day, that Nakamura invented the light bulb or to put it correctly that Nakamura re-invented the light bulb. Shuji Nakamura's inspiring story has been told before but here is an ultra-short version of it

Nakamura gets a masters from a relatively small university in a small city in Japan, goes off to work in a small company in a lab competes against the big companies, discovers many right things and makes products that would not sell.

Times get difficult, his department shrinks. He goes to his boss and wants to make a product that the big boys have tried to make and failed; with his record, he gets turned down. He goes to his boss's boss and gets some support to make it, despite his record of making nothing that sold, his company chairman gives him money, $2mil actually and he reinvents the light bulb. Well, he actually gets the blue component of the LED to work and the rest is history.

What is interesting is that Nakamura was a non-PhD working in the industry as a lab scientist who then gets a doctorate from his local university and within 5 years is head hunted by University of California and becomes a professor.

Nakamuras in NHS?

Let us imagine a scenario of a doctor who becomes a consultant in a DGH in the NHS and wants to do something that the big boys tried and failed.Then the DGH consultant fails as well, fails repeatedly - what are the chances that he will not be performance managed out of his/her activity and driven to the end of his wits.

What are the chances that the medical director or CD will be over-ruled by the CEO or Chairman and a doctor provided funding to carry on despite a record of 'failure'? What are the chances that even after this doctor discovered something interesting a big place will head hunt and make him/her an 'academic'? In fact he/she should be grateful if the GMC and the rest of the regulation did not land on him/her and crushed him/her out of existence.

Getting real

Now a lot of you are going to say that reinventing a light bulb while surely profound is unlikely to involve any damage to real human beings. You might say that any lurking Nakamuras in the NHS if supported could end up hurting patients. Good logical argument. Is that what is really hurting patients? Probably not. It is not any innovation by enthusiastic people that harms patients, it is the bureaucratic nay sayers who use the language of clinical governance and risk yet know very little about process capabilities, refuse to learn shared baselines, practice unimaginatively poor leadership who perpetuate harm in healthcare. They refuse to fix the system instead try to 'fix' the people in the system. Of course the medical profession does not do itself any favours by its ego, jealousy and macho attitude which will aim to shoot down anything that arises outside its hierarchical constraints by treating them as bad apples and recommending the use of evidence the origins of which  can probably attributed to the Abilene paradox.

In healthcare especially in the NHS it is pretty much impossible these days to take an extra breath without CD, CG, R&D, GCP, LREC, NREC, NICE, and every other alphabet in the soup wanting to spoil it for you, while claiming to support you. It is when people who are typically NHS managers and every other hierarchical bureaucrat stops behaving like researchers and most doctors who are not researchers begin to look at operational evidence as a valid method of creating a new practices, innovation and improvement that healthcare will be truly successful.

Allowing and managing 'Nakamuras' in healthcare is not easy but will be rewarding; eliminating the healthcare 'Nakamuras' will allow the managers to sleep peacefully but might push true healthcare innovation into a coma.

If you know of any 'Nakamuras' in the NHS please let me know by leaving a comment below.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Links & reference
The dream of the blue laser diode
http://engphys.mcmaster.ca/undergraduate/outlines/4e03/Nichia%20%27s%20Shuji%20Nakamura%20Dream%20of%20the%20Blue%20Laser%20Diode.htm
Time magazine short feature on Nakamura
http://www.time.com/time/magazine/article/0,9171,1604891,00.html

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

 

Blame it on human error

Blame it on 'Human Error', after all everybody knows that to Err is Human

Can you see what is happening in the pictures above? Of course you can. They are two infusion pumps with two different types of numerical key pads.

Can you now see how easy it would be for a tired nurse or an even more tired doctor when they are really busy at 3 am to confuse between the keypads and make a mistake?

Would that be counted as human error? Probably yes. But is that human error? Certainly not. This situation would be without doubt a systems error at two levels. Firstly for the manufacturers not standardising numerical keypads. Secondly for the buyer/healthcare facility for buying and using pumps with two different key pads in their premises. By doing so we have designed our system to fail, we have designed for the humans in our systems to fail. Avoiding that is what human factors is all about.

Let us assume that a clinician made an error in a facility that both these styles of numerical keypads in use in say adjacent beds/wards/floors. The investigation would only show that the clinician made a human error in pressing the wrong numbers in that particular key pad. That would be a fact. Would that be the whole truth? No. A standard investigation would not show that the error was triggered by the system by having those two types of keypads in adjacent areas. The investigation would probably end by stating that individual clinicians are responsible for their actions. Then the clinician would be sanctioned against, sometimes that is insultingly yet euphemistically called providing enhanced support and training for the concerned clinician.

The reason called 'human error' becomes a convenient parking lot for system errors that mostly go unrecognised due to poor management and poor investigators who have not much clue about human factors. Human error is easy, its tangible, you have someone clearly responsible and someone who has failed in their responsibility. Every one understands human error. System error recognition is very complex, its often fuzzy, once recognised there is no one to 'blame', to be held responsible. After all that, resolving system errors takes patience, time, energy and technical skills which many would pretend to have. It is frightening to imagine how many clinicians might have been afflicted with the 'human error' label when the actual reason was the system.

Now, if you were remotely responsible for patient safety, you will now rush out into your healthcare facility to make sure that you have only type of numerical keypads at your facility for these. That is at the narrow level. At the intermediate level please ask yourself how many other items that are non-standard at your place of work that confuses people and compels them into making an error. Go looking for them and eliminate them.

At a bigger picture level we are beginning to believe that 'Human Error' is often a cop out clause for managers who don't fully understand systems or processes. To err is indeed human but to design for failure and then blame it on 'human error' is inhuman.

©M HEMADRI 

Follow me on twitter @HemadriTweets

PS: Note the manufacturer of the pumps in the picture above is only an illustration to make a wider point, those pumps are good and overall have served patients well.  So please do not get hung up and pious about a particular product or company. I have also found that my windows calculator and my samsung phone calculator have different numerical keypads which are different from my computer keyboard's numerical keypad. How confusing is that? Is it any wonder then if some poor bloke at the office goofs up?