Welcome to 2016! I hope you enjoyed the various breaks we have had and were prepared
for the third biggest snowfall in Lubbock’s recorded weather history. Now, back to
business.
Texas has two nuclear power plants each with two reactors. One is located near Houston
and the other near Fort Worth in the small community of Glen Rose, which you may have
visited to look at dinosaur tracks. I had the opportunity to take a comprehensive
tour of the nuclear power plant in Glen Rose a few years ago. We had to don protective
suits and badges, stay together as a group and be checked with a Geiger counter before
and after leaving certain restricted areas. We were even fingerprinted. Guards were
walking around with M240 machine guns and they looked like they meant business. Mistakes
are not allowed there because if they occur, the consequences can be devastating.
Health care delivery is similar. We can say that mistakes are not allowed, but as
long as human beings are involved, mistakes will happen as a fact of life. I bring
all of this up to say that we can learn lessons on how to reduce the likelihood of
mistakes from high-risk industries such as nuclear power and aviation. In these industries,
great emphasis is placed on “systems”. Patient safety experts believe that most medical
errors are due not to incompetent providers; but, rather due to flaws in the systems
of care. These flaws are often referred to as latent errors and represent issues in
health care systems that made the error itself more likely to happen.
Latent errors include such things as poor design, incorrect installation, faulty maintenance,
poor purchasing decisions and inadequate staffing. These are hard to catch because
they might exist for a long period of time before they lead to an adverse event.
An active error, on the other hand, occurs at the level of the frontline provider,
such as administration of the wrong dose of a medication, and is easier to measure
because it is limited in time and space.
These systems issues are important because there is a tendency to blame the involved
health care providers when a mistake occurs, who are not necessarily at fault. We
must learn to be thoughtful when problems occur and avoid a culture of blame concerning
health care errors in order to learn from them. For example, I recently wrote about
a mix-up of salt and sugar in baby formula at a New York hospital in the early 1960s
that led to multiple infant deaths. My point was to demonstrate the importance of
paying attention. But, was it the fault of one person or was it the system’s problem
of improperly labeled ingredients?
Neither safety experts nor I say the individual does not have personal responsibility
for doing things right. However, in 2016, let us think about and fix those things
that might be latent problems. Maybe it is the handling of expired medications, how
we store drugs or what is in the crash cart. As my and probably your parents said,
“That is an accident waiting to happen.” When we identify such, let’s fix the situation.
Sometimes it takes more than one individual or even one department to address these
accidents waiting to happen or actual mistakes that occur. The most important step
we can all take, regardless of our role or position is not to be reluctant to report
and share these issues. In the next couple of months, we will begin implementing a
new automated reporting system. It is important that all leaders encourage staff to
report near misses and actual occurrences as soon as they occur without fear of retribution
or blame. Accidents will always happen in health care but with vigilance and reporting,
those accidents will be rare and Texas Tech Physicians will be a safer place for patients
to receive their care.
