Lean Education Error Proofing

The tool What is it? What’s it for? How does it work? When do you use it? What’s an example?

What is it? Error Proofing is a method of identifying ways to eliminate or reduce errors in a process There are multiple levels of solutions Level 1 – total elimination Level 2 – reduction of error rate (when elimination not possible)

Error Proofing – Is it Needed? “Between 44,000 and 98,000 people die each year nationwide as a result of avoidable errors in hospitals… Safety does not reside in a person, device or department, but emerges from the interactions of components of a system.” Errors can include problems in practice, products, procedures and systems. The usual responses to such errors focus on preventing recurrence by punishing or retraining individuals. These responses tend to be ineffective because they ignore the system and instead focus on one particular set of circumstances that are unlikely to reoccur. To Err is Human: Building a Safer Health System, Institute of Medicine (IOM) Read for Free at: http://www.nap.edu/books/0309068371/html/

Error Proofing – Is it Needed? Kidney Transplant wrong side Unnecessary radical jaw surgery Surgical sponge and gauze left in breast Surgical tool left in stomach The New York Times Magazine, March 16, 2003

Error Proofing – Is it Needed? OLD Dennis Quaid on 60 Minutes last week? He talked about the sad case where his twin babies were mistakenly overdosed TWICE at Cedar-Sinai Hospital in Los Angeles. His babies are recovered now, thankfully. The silver lining on the sad case is that Quaid, as an actor and celebrity can become a powerful voice and advocate for patient safety and preventing systemic errors - highlighting the problem AND suggesting countermeasures and systemic fixes. As Quaid recounted the story, he first seemed to blame the nurse: "The nurse didn't bother to look" at the dose (the correct dose, on the right, and the incorrect dose are both pictured here). Later, he mentioned, correctly, that a series of errors had occurred. As I've said before, it's too simplistic to just blame or punish a single person when an error like this occurs. That approach certainly doesn't help prevent other such errors. He said the babies had been given TWO massive overdoses in an 8-hour period "that we know of," he said -- again, the signs that there's suspicion of a cover-up. It also highlights what a systemic error this is, that it could happen twice in the same hospital. It was a chain of errors that occurred. First, someone in the pharmacy picked the wrong dose. Secondly, a pharmacist is supposed to double-check any medications that leave the pharmacy (an inspection step). That's two people who are supposed to "bother" to look at the label. Then, there's the person who delivers the medication to the ICU. Finally, the nurse is the last in that chain. But, the nurse isn't expecting that the adult dose of Heparin is even there in a neonatal unit. So, pretty easy to let your guard down, right? I don't think that's an excuse, that's just reality. Quaid was right to say the errors were "avoidable" -- pointing out it was the same avoidable errors as the case where three babies died at Methodist in Indianapolis. Quaid has become pretty obsessed with researching the topic (he was shown on the computer, maybe he's been on this blog?) and discovered the errors happen "everywhere." He cited the "100,000 deaths a year" number (which comes from the late 90's study from the Institute of Medicine. Quaid said, "This is bigger than AIDS, bigger than breast cancer... yet nobody seems to be really aware of the problem." I'm glad Quaid is trying to spread the word and to help others. There was a lot of talking about the old labeling being too similar across the two bottles. The new label (pictured on the right) is better because it's not just a different shade of blue and it requires a different motion (tearing off a paper cover) that is not required for the smaller Hep-Lock dose that is intended for babies. The old stock (the old, more mistakable labels) was NOT recalled. Cedar-Sinai was using up their old stock first (sure, it was "FIFO" or First-In-First-Out, something Lean folks generally like), but that shouldn't have been the case when safety was at risk. What responsibility does hospital administration take for this materials decision? The maker of the drugs, Baxter, had a spokesperson on 60 Minutes who reminded us that people were supposed to read the label (again, casting blame), even though the labels had been mistaken many times before by other nurses in other hospitals. But they redesigned the labels after earlier incidents. It was not necessary to recall, 60 Minutes asked? The Baxter spokesperson said "No, the drugs were safe" and that it was due to preventable errors in the hospital's system. The CEO of Cedar-Sinai admits it was human error, preventable error. The CEO said "you need backup systems" and CBS's Steve Kroft asked, "but you had backup systems, you had three people." How many more backups can you add? More inspections and more backups isn't necessarily more effective due to, here it is again, "human error" in inspection. When many people are checking something, it's human nature to let your guard down because the "other person" will get it. CNN, November 21, 2007 NEW

How does it work? Weaknesses in processes are identified by observation, measurement, or other methods Ideas for eliminating errors are collected, evaluated, and tested The most effective and practical solution(s) are implemented

When do you use it? When errors are identified and are causing a process to be inefficient When harm is coming to patients, regardless of frequency or difficulty of correction

Process for avoiding simple human errors: Error Proofing Process for avoiding simple human errors: Makes Zero Defects possible Eliminates need for additional inspections Shows respect for intelligent workers Frees a worker’s time and mind to pursue creative, value-adding activities Attitude: It is NOT acceptable to produce even a small number of defects

Level 1: Total Prevention Defect cannot be made Outlets for various types of gases are “keyed” in such a way that wrong connections can not be made. All connectors have a pin at the 12 o’clock position, but differ on the second position. Level 1: Keying Level 2: Color Coding “Condition H” (Shadyside, Patient/Family call for RRT Credit to John Grout, Berry College, www.mistakeproofing.com/medical

Level 1: Total Prevention Defect cannot be made Error: esophageal intubation (putting a tube into a patient’s stomach which was intended for their lungs) Error proof: Squeeze bulb and put on tube. If bulb inflates, the tube is in the lungs. If not, tube is incorrectly placed in the esophagus. Another example is the esophageal intubation detector. You intubate the patient; you take the bulb; you squeeze it; you put it on the tube; you let go. If it inflates it is in the right spot. If it fails to inflate fully, it is an error. You then re-intubate and try again but this way you don't have to use any radiology. You don't have to use touch or feel to decide if it is right or not. You know right away. Credit to John Grout, www.mistakeproofing.com/medindex.html

Level 2: Hand Washing Before Entry Light Sensor under Sanitizers – both inside room and out – raises the “Stop” arm “Stop”/Go Arm is Up Kevin Frieswick at MetroWest Medical Center http://www.leanblog.org/2009/04/leanblog-podcast-65-error-proofing/

More Error Proofing Examples NG tube cannot be connected to an IV port Yellow tubing is attached to all epidural meds and serves as a visual indicator http://mmpp.wikispaces.com/

Error Proofing in Practice Lab: Barcode scanner was implemented to scan and identify specimens quickly and without errors. ER: Pyxis-for all critical supplies; not just for drugs

Error Proofing in Practice Sanjay Saint, MD, Univ. of Michigan Healthcare System implemented a reminder system for physicians to remove the urinary catheters of hospitalized patients. Indwelling urinary catheters are placed in ~25% of hospital patients. Estimated 40% of infections developed during hospital stay are urinary tracts infections, most due to urinary catheters. The reminder system error proofs the process by helping the doctor know which patients have catheters, how long they have been in, and when to order removal. Study results showed that each patient’s hospital stay that involved a catheter went down by 7.6% on the “reminder” wards. And, the written-reminder system isn’t expensive. Dr. Sanjay Saint UMHS in BCBSM’s Highlights Newsletter Read for Free at: http://www.bcbsm.com/foundation/pdf/05highlights.pdf

Questions?