Reliability and Patient Safety

”Curmudge, if you could foresee that you would be run over by a giant turtle while you are jogging tonight, what words of wisdom about patient safety would you gasp with your final breath?”

“Turtle? Don’t you mean Beetle? There may still be a few that haven’t rusted away.”

“No, I really mean turtle. I know how slowly you jog. So, Speedy, what would be your final words?”

“Well, if you must know: ‘We must be serious about patient safety and do the right thing right the first time every time. That requires know-how, systems designed for safety, and a safety culture exhibited by everyone involved.’”

“Okay, Curmudge, let’s assume you survived your 22-minute mile unscathed and can discuss patient safety at your leisure. What’s our first topic?”

“Let’s start with the need to address patient safety. Regrettably, the story about Stan that I related last week is not a once-in-100-years event. Most patients approach a medical procedure with confidence in achieving a favorable outcome. An informed patient will approach the same procedure with trepidation. ‘In health care delivery, a defect—an error, omission, or other failure to accomplish an intended action—occurs, on average, 10 to 20 percent of the time, compared to 0.0001 percent of the time for airlines and nuclear power plants.’(1) It is evident that health care has a reliability problem.”

“Hey, that’s pretty scary, Curmudge. But how about this: The 100 thousand deaths per year in hospitals purported to result from medical errors would be equivalent to the lives lost in four jumbo jet crashes per week.(2) Maybe I should give those numbers to my hypochondriac mother-in-law. She’s afraid to fly, but she thinks a hospital is just like a hotel with room service providing all the meals.”

“Julie, the Institute for Healthcare Improvement (IHI) has developed a framework for improved reliability based on industrial principles of standardization.(3) It begins with protocols of care that are evidence based and widely agreed upon. As IHI says, ‘Standardization is crucial to improvement, because that’s what promotes reliability.’”

“I see now, Curmudge, why we talked about standard work a few weeks ago.”

“The IHI framework employs a three-tiered strategy:
· Prevent failure using guidelines, checklists, and other techniques for best-practice treatment of specific conditions.
· Identify and mitigate failure by using standing orders for best-practice treatments, warnings when an undesirable event is approaching, and independent double-checking of required actions.
· Redesign for success after root cause analysis of persistent failure reveals a flaw in the system design.”

“I presume that IHI’s ‘bundles’ that we discussed two weeks ago were a product of this effort. So we know the importance of standardization; what else must a hospital do to keep its patients safe?”

“Let’s continue this next week, Julie. We’ve got lots to talk about, so you’d better ask your husband to fix supper for the kids.”

“Sure…and supper will be potato chips and toasted Pop-Tarts.”

Affinity’s Kaizen Curmudgeon

(1)http://www.ihi.org/IHI/Topics/Reliability/ReliabilityGeneral/ImprovementStories/WhenGoodEnoughIsntGoodEnoughTheCaseforReliability.htm

(2)Karl, R.C., Staying Safe: Simple tools for safe surgery. Bulletin of the American College of Surgeons 92 (4):16-22 (April, 2007).
(3)http://www.ihi.org/IHI/Results/WhitePapers/ImprovingtheReliabilityofHealthCare.htm