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 

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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

 

Increased Quality and Reduced Cost - Possible in India

I have a long held view that quality is inversely proportional to cost which means as for a given activity as the quality improves cost decreases. This is actually possible in India as well.

Let me share a clinical anecdote that may illustrate my point. It may be dated and trivial to many current readers but was very relevant to the patients and clinicians at that time.

In the late 1990s I was working as a surgeon in Sir Ivan Stedford Hospital, Ambattur, Chennai, India (http://www.ammfoundation.org/SirIvanStedefordHospital/index.html). This is a charitable hospital where we used to charge very small nominal amounts of money to provide services. A few rupees for out-patients, few tens of rupees for scans and so on. Being India, one of the commonest operations performed happened to be surgery for hydrocele. The way it was conventionally performed may be very familiar to many of you. The operation of course ended with a large bandage tightly applied to the scrotum with the purposes of avoiding problems like pain, infection, haematoma, oedema etc. These patients were also put on antibiotics for 10 days or more. Many of these patients used to come back with soiled dressings and the exact problems that doctors were trying to avoid. Doctors used to wonder what else could be done to improve the situation.

Not using a bandage was thought to remove an all important barrier that avoided exposure of the scrotal wound to the unhygienic toilet situation in India and despite using 10 days or more of antibiotics infections were happening. Barrier and antibiotics thought to be bulwarks against contamination and infections were not working.

I actually thought the tightness of the bandage caused oedema and increased pain. The presence of the bandage increased sweat and moisture in an already humid perineal area in a warm country. The bandage also easily became wet because of the toilet washing habits of the country and acted as a rich environment to create infections.

Having worked in England where the scrotal bandage was not routinely used after scrotal surgery, I took the bold step of not using scrotal bandages to hydrocelectomy patients much against the advise of my friends and colleagues. Of course, I suggested the use of the proper scrotal support clinical hosiery which was either not available or when available was very expensive. An alternative had to be found. I simply asked my patients to buy 7 of the cheapest 'A' or 'Y' front underpants from the shops opposite the hospital otherwise I would not operate on them. I used these normal commercially sold underpants over a couple of pieces of sterile gauze placed on the scar, changed once a day by the patients themselves, in the place of scrotal bandages for my patients changed by clinical people. Most of my patients found this very amusing. Some were resistant, perhaps hesitant, because the had not worn such a type of undergarment before. My colleagues were of course greatly humoured by what they thought was my naivety and enthusiasm.

In a few weeks, post operative follow up clinics were showing that my patients were walking in and walking out in super speed and for the rest of the surgical team there remained the usual levels of post op problems with pain, oedema, infections. Having eliminated the scrotal bandage which I thought was causing the problems, I then moved to single dose prophylactic antibiotic as I used to do in Britain.

Word of mouth and social observations in a local context those days was of course as fast as twitter or facebook now. The talk was about how patients spent less money on changing bandages and buying antibiotics while getting good results. Soon my colleagues avoided scrotal bandages, used undergarments as I recommended and moved to a shorter course of antibiotics often just 3 doses (instead of the usual 10 days).

Of course the people who charged for the change of dressings and the people who sold antibiotics were not happy. But I can tell you who were happy, the guys who sold the undergarments. They were really happy. 7 undergarments per hydrocelectomy patient in a hospital that did hundreds of hydrocelectomies, they must have been ecstatic. Well, I know they were, as one of them approached me and offered a commission to me (his bloody nerve) if I could recommend patients to buy the undergarments specifically from his shop – no different from the drug store chap then!

Clinical complications reduced – i.e. quality improved. Cost reduced.

Okay, this example is not about whole systems, scientific proof, published evidence and other high & mighty things. It is one little example. What I cared and what our patients cared is that we had lesser clinical problems and we achieved it by doing/using/costing less. Perhaps hydrocele surgeons in India are no longer using scrotal bandages and 10 days antibiotics - that is why this anecdote may be very dated but the general lessons are in my view still valid.

Increasing quality while decreasing costs can be achieved in India as well. Perhaps due to the large number of people who are around the poverty line this concept becomes even more relevant to India. We must remember that though the GDP is high the per-capita money is very low in India. Individual doctors are not dealing with the mighty high GDP India; individual doctors deal with the individual patients of low per-capita India. That is why low cost high quality care becomes essential.

©M HEMADRI 

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High Mortality Hospitals Cannot Afford To Pay

In a previous post I showed that most high mortality trusts did not pay bank holiday extra rates/wages to staff for the Queen’s diamond jubilee bank holiday, while most low mortality trusts paid higher wages. 

 

A friend of mine who is an academic wrote back to me and said he could not resist doing a chi square on the numbers and found the p=0.01. I am no don to argue or explain stats but irrespective of statistical significance it is important to probe if there might be a deeper meaning or relevance. 

 

It is important to understand why the high mortality trusts did not pay higher holiday rates. Are they ‘mean spirited’ as the Unite Union portrayed them?

In my mind the underlying reasons are very simple and here it is:

QUALITY IS INVERSELY PROPORTIONAL TO COST 

 

And a high HSMR is broadly speaking poor quality care.

Financial reasons?

It might be something as simple as they had no money left to pay. Now that would be a perfectly reasonable assumption to make. Trusts get paid for activity, things like hernia repairs, aneurysm repairs, cardiac stenting, the kinds of things that you do to make patients get better. As far as I know the NHS tariff system through which the trusts get paid does not include things like deaths or complications. 

But in-hospital deaths are very costly; in-hospital complications are very costly. There is no mechanism for payment for that. So a hospital/trust which has high deaths and complications will obviously not have money to do anything else.

Well, it therefore might turn out that their inability to pay higher wages had no a financial reason at all; it may well be a by product of poor quality. High cost, deficits, losses are all a function of poor quality. 

 

If you pushed them they will come out with something like ‘in this financial climate we would like to channel all our sparse finances directly into patient care’ and you know what, they sure do; their patient care must cost excessive amounts of money due to higher rates of standardised mortality and higher complications.

Cultural reasons?

Perhaps they were unwilling to pay higher rates; management might not have felt the need to 'reward' staff who are unable to produce high quality measured in terms of mortality. Another reason might have been that the money might be better spent in a high mortality hospital in trying to reduce the mortality rather than paying more to staff when the law does not demand that you do so. These are a part of the mental make up and cultural reasons of management. They are right, well, partly right. It is also just possible that well rewarded staff might be motivated to engage in improvement. Works both ways but always difficult to decide which one is right for the given circumstances.

Finally, here is some speculation

But, why did some high mortality hospitals pay staff bank holiday wages? Surely the above arguments apply to them as well. Why did some low mortality hospitals not pay higher bank holiday wages? 

 

Now I am moving into speculation something which I try not to do too often. My gut feeling is that the high mortality hospitals who paid a higher wage are probably going to find reduced mortality soon or at the best they may continue to stay where they without slipping and getting any worse and the low mortality hospitals who did not pay may find their mortality going up or at the best they may stay where they are without getting any better

 

My speculation is an extension of my theory about money in hospitals, the trusts who are doing clinically well might have the spare cash to spend it on staff. If that was indeed the case, the staff deserve it.

©M HEMADRI 

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Hemadri's Four Fundamental Questions for Clinical Quality Improvement

Hemadri's 4 fundamental questions for Clinical Quality Improvement

1) Do you have local clinicians' agreement on clinical healthcare delivery? (Doing the same thing by all professionals in the same manner for the same condition)

2) Are you measuring the right things in the right manner? (Measuring process and outcomes over time)

3) Do you have a human approach to leadership and management? (In other words do your staff love you, do your patients love you? Working with and enjoying ambiguity and limitations)

4) Can you prove meaningfully that you have shared to others and you have learned from others within your organisation? (Proof that every individual does whole system improvement)


To some of you these four questions might sound like cliches. To some of you these might be stating the blindingly obvious. The questions are not 'lay'; they are highly technical questions with strong theories and some practical examples behind them. There are specific and explicit frameworks, methods and techniques to explore these questions and then to make them happen.

There is a general impression that healthcare does all the four well; especially if you work in healthcare you may be tempted to answer 'Yes' to all the four questions. You may even proceed to argue and 'prove' it. There is much evidence that healthcare in general lacks all the above four. The chances are it will be surprising if many areas of healthcare delivery had even one of these. But once these questions can be answered with a real 'Yes' healthcare leaps into a bright better zone.

Success in Healthcare can be found only if the the answers to all the four questions can be a clearly demonstrated 'YES'.

We explore these at the CQI to some extent. I am hoping that over a period of time I should be able to blog about these things in specific detail rather than in broad general terms. Perhaps even write a book.

© HEMADRI

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