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Healthcare Quality and Error Reduction

Errors are difficult to measure—not only because of inadequate reporting and varied definitions, but also because most errors are not a single act but a chain of events. For example, prescribing the wrong dose of a drug may be counted as a single error and given a single name, such as a "prescription error," but the physician's prescribing error may have occurred because the medical record contained an incorrect body weight or because a laboratory report was missing. Researchers and administrators ignore the complexity and systems that can produce skewed statistics and propagate imprecise notions about the anatomy, causes, and consequences of errors. A better way to address medical errors would be to develop a cascading model that can be addressed by the Six Sigma approach to process evaluation.

In other words, in a process management environment that Six Sigma promotes, we are not simply looking for the cause of an error for the error's sake; we are instead looking for a total understanding of the process that led up to the error. As many of us have discovered, very seldom do we find anything in this world that is actually black and white—and the same is true of medical errors. Many times the error is caused by a single small and seemingly insignificant error or process breakdown that cascades into something much larger. As an example, consider a lab slip that travels from the unit secretary to the lab, and back to the patient's room. How many opportunities might that slip have had to pick up a bacterial agent in route? Then consider that the slip is dropped in the hallway and picked up by a nurse who then comes in contact with another patient and now cross-infects another patient. It's a seemingly minor incident and, given the frequency of handwashing, it's probably not in your healthcare organization.

This is apparently not the case in Pennsylvania where the Pennsylvania Health Care Cost Containment Council reported in March 2006 that hospitals in Pennsylvania alone reported 13,711 infections during the first nine months of 2005 compared with 11,688 for all of 2004. The infections were associated with an additional 1,456 deaths, 227,000 extra hospital days, and an added $52,600 to treat every patient. As the old saying goes, for lack of a nail, the battle was lost.... Perhaps the saying should be revised to say that for lack of a lab information system, the patient died. Of course, it is irresponsible to suggest that any of these infections were caused by the lack of a lab order information system—but is it any less irresponsible than not finding out why these infections were caused in the first place. To fail to understand the process and the opportunities for "errors" is perhaps the most irresponsible part of the equation.

Why It's Difficult to Deal with Healthcare Errors

If you as the reader are looking for some great insight into why we fail to act aggressively in regards to healthcare errors, the debate has been discussed without resolve for years—defensive medicine.

Defensive medicine merely means that in a litigious society, we order extra tests and don't really pursue the cause of errors as aggressively as we might if it weren't financially devastating to be found guilty of making an error—an error that in most cases could have been avoided had the process been designed so as to eliminate or at least mitigate the opportunity for error.

Consider the multiple stories of hospital operating rooms that amputated the incorrect limb on patients. The best advice I have read on dealing with this blatant process breakdown is for patients themselves to write in permanent ink on the affected limb "amputate this one" and "don't amputate this one" on the other limb. Granted, an amusing story for the press, but a tragic reflection on our healthcare providers when they can't get something as simple as amputating the correct limb right. An even better question is why the patient is advised to do the labeling themselves? It seems to me that we could have figured this one out ourselves years ago. Labeling a limb is a low-tech solution to a catastrophic problem that easily could have been generated by an astute Six Sigma quality team.

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