Archive for the ‘human error’ Category

When sorry isnt the hardest word

In adverse events, human error, Human Factors, Interuptions, Multitasking on December 14, 2014 at 8:49 am

On Monday afternoon, a tragic medication error occurred at St. Charles Bend that ultimately caused the death Wednesday of a 65-year-old patient. The St. Charles family is devastated by this situation and our thoughts and prayers go out to the patient’s family along with the caregivers who were directly involved in this case during this incredibly difficult time.

“As soon as the error was recognized, we met with the patient’s family to explain what had happened and apologized for the grave mistake. We are in the process of investigating the cause of the error and are working closely with our internal team to ensure that it will not happen again. We will be reporting the event to The Joint Commission and the Oregon Patient Safety Commission in the coming days. St. Charles has never experienced a medication error of this kind in its history.

On the surface St Charles did everything right by the family in this tragic medication error. They owned the mistake, did not blame it on individual practitioners and they apologized to the family. They go on to decribe the process by which a paralytic was dispensed instead of a seizure medication. they performed a root cause analysis and came out with an action plan. They appear committed to this action plan on every level of their organization and they seem sincere in their determination to prevent this from ever happening to another patient.

Since Ms. Macpherson’s death, we have taken several immediate steps to ensure that an error of this kind will not happen again in our facilities.
Issue 1: Incorrect drug chosen and placed into IV
Our Response: We are enforcing a “safety zone” where pharmacists and techs are working that is intended to eliminate distractions. Verification of medication can only be completed in these areas.
Issue 2: Verification of drug dispensed
Our Response: A detailed checking process has been standardized and implemented to bring heightened awareness to the pharmacy team. New alert stickers have been added to paralytic medications and we are training nursing staff to watch for these stickers.
Issue 3: Monitoring of patient after IV started
Our Response: Nursing leaders are currently evaluating patient care processes to ensure we are following best practices. On every unit, our nurses are being hyper-vigilant about how we administer any intravenous medications. We are conducting frequent check-ins with our patients and we are consulting with patient safety experts across the country to ensure we are adhering to best practices.

The words that scare me in their action plan are those like “safety zone” “heightened awareness” and “hyper-vigilant.”
While these are admirable and many errors are caught by caregivers because of these very things, this is like medicating for an illness to cover the symptoms instead of giving a patient the cure.
Instead of a safety zone, move the dangerous drugs to another area that can only be accessed and prepared into a bag of IVF with the assistance of barcode scanning.
Instead of heightened awareness and stickers, manufacturers should make special syringes and tubing for high risk medications so they cannot be given inadvertantly.
Instead of hyper vigilance, establish staffing patterns that ensure nurses can focus on one patient at a time instead of continually multitasking. Study “priority setting” and how leaders can support front line staff by spelling out how to manage busy shifts (eg. what are essential practices for safety and what are second tier priorities like patient experience. High profile initiatives can come across as if they are more important than safety).
Proactively observe the medication process and visit nursing units to get staff’s ideas on what might be the next be error. Your staff know.
The heightened awareness and hyper-vigilance are totally people based interventions. If another medication error is made, I fear the staff will be blamed for their failure to maintain these super-human standards.

Visit for more info about the apology

“They killed my patient then tried to hide it!”

In adverse events, human error on September 22, 2013 at 5:54 am

Scroll down to read a Blog post from a Boston area MD. I think somehow hospital administrators/boards justify this type of behavior in the name of the greater good (eg. keeping hospitals open and people in awe of their ability to heal..see Placebo). I think many healthcare workers have had their stories “changed” during investigations in which a hospital might have liability and have certainly been told things by lawyers that are less than the truth. Been there.

Let’s remember, the anesthesiologists involved doubtfully went to work that day planning to kill a pregnant woman! I wish the Md in this post (and the hospital) had been a little more understanding about human error. An admission of error followed by apology, full disclosure and just compensation by the hospital could have spared the family the trauma of a lawsuit and prevented the author of the following blog post from harboring angry feelings so many years later.

Find the mistake

In adverse events, human error, Human Factors, Root cause analysis on February 2, 2013 at 5:56 pm


This mini human factors test is going around Facebook.
Once you find the mistake it becomes almost impossible not to see it.

This illustrates two concepts
1) we see what we expect to see and our brain “corrects” what does not conform and therefore we can easily misread labels
2) Only hindsght is 20/20. When investigating an error after the fact, hindsight bias may cause one to think the error was foolish and was easy to detect at the time. Now that you see the error in this little picture it seems to be so evident that you wonder how it could have been missed initially

This is why we need barcode medication identification systems for preparation and administration.
And this is why it is so important to understand what was actually known at the time of an error and not what we know in hindsight. Many errors occur when people are doing what they always have done. Usually there is no significiant deviation from norm.

Propublica series on Patient Safety

In hospital, human error on January 5, 2013 at 7:22 pm

From their website:
Too many patients suffer harm instead of healing in U.S. medicine. That’s why ProPublica’s reporters have investigated everything from deadly dialysis centers and dangerous hospitals to the failure of state boards to discipline incompetent nurses.

This page allows patients, providers and readers to join the patient safety conversation. Our goal is to find out why so many patients are suffering harm and highlight the best ways to solve the problem. Here you’ll find regular updates, and places to share your stories, views or expertise.

Read all of our posts on patient safety, and find out how to get involved.

When productivity trumps safety we all lose.

In human error, Normal Accident Theory, Resiliency, Safety climate on September 30, 2012 at 9:32 am

““You are judged by numbers in the lab,” McShane said. “There is a culture of pressure to get it done with no new ­resources. But there is no ­excuse for [cheating] at the end of the day.” (, 2012)

So goes the story of Annie Dookan, a chemist in a Massachusetts crime lab who is suspected of compromising evidence in many of the 34000 samples she has tested in her 9 year career.  Her motivation seems to be no more nefarious than trying to look like a stellar employee.

What does this have to do with patient safety? It is common in hospitals today to push the border in terms of productivity.  Add some more patients, add new procedures, add no more  staff.  In safety studies this can result in what is known as drift.  You get through one shift with suboptimal staffing and nothing bad happens so you chance it again, then again, and little by little in order to cope: staff develop workarounds and short cuts that all begin to be seen as normal (culture) and less risky as staff has not gotten feedback on any bad results. If staff continue to be judged on output (census, patient turnover, lower expenditures) they will seek to make these their priority rather than follow safe procedures.

According to Cook (2000) work processes do not chose failure but drift toward it as production pressures and change erode the defenses that normally keep failure at a distance. “This drift is the result of systematic, predictable organizational factors at work, not simply erratic individuals.  To understand how failure sometimes happens, one must first understand how success is obtained-people learn and adapt to create safety in a world fraught with gaps, hazards, trade-offs, and multiple goals.”

In safety critical environments that deal with people’s lives, leaders should be preoccupied with failure not productivity. A leader is responsible to identify drifts by being present in daily processes. Drifts can be identified by observing staff behaviors, reviewing peer reports and asking people what types of things they are worried about. Asking staff to “do their best” without a supporting environment will not result in a high performing system. Productivity goals should be made based on an analysis of the work not by how much money is in the budget. I think it’s time as a nation we say in all instances “if there isnt enough money to do things right, don’t do them at all.”

 Annie Dookin made some bad choices but she worked in an environment where bad choices were acceptable and when peers did speak up, nothing was done. Who is responsible for this?

And who is responsible for the incarceration or punnishment of some people who might be innocent who are imprisoned: all because a culture of productivity over-ranked safe procedures. In these circumstances, just as in healthcare, humans always suffer.

Safety first. Productivity second. These cannot just be words and slogans. They have to be guiding principles that are evident in everything we do, in healthcare and in crime labs.  It scares me that this lab was run by……..The Department of Public Health 😦

Holy toledo! A lost kidney?

In culture, human error on September 26, 2012 at 7:58 pm

The story of a kidney thrown out by accident during surgery to remove said kidney for the donor to donate to her sister!

Horrible incident… the nurses were fired…wrong solution.  blame and shame will not fix a major problem like this!

This seems like a total system/ culture issue as no one in the room who knew the kidney was in the items that were thrown out spoke up!

TED talks: Medical Mistakes

In human error, Patient Safety on July 12, 2012 at 10:42 am

Dr Brian Goldman talks about error stats in an easy to understand analogy to baseball

Human error and Hepatitis C

In human error, Resiliency on December 31, 2011 at 4:59 pm

The investigation of how a child in Boston received Hepatitis C via cardiac surgery in which blood vessel tissue was transplanted, revealed a case of human error in reading the hepatitis status of the donor back in March.

Human error WILL occur and resilience in catching and responding to these errors is what will keep patients safe.  Resiliency is the ability of a system to adjust its functioning in the event of a mishap or under a state of continuous stress (Nemeth, Wares, Woods, Honagell & Cook, 2008).   Even after the error in reading the tissue occurred there was opportunity to prevent the error from reaching the child.  Another person who had received a kidney from the same donor tested positive for Hepatitis C but it was 11 days before a communication occurred with the Office of Blood, Organ, and Other Tissue Safety at the CDC (Conaboy, 2011, Boston Globe).  The child’s surgery was performed 3 days before the official communication but 8 days after the kidney recipient tested positive.  As soon as the first kidney recipient tested positive, the human error should have been discovered and further infections could have been prevented.  A human error occurred but system problems and communication impairments made this a larger catastrophe than it should have been.  This illustrates that while the sharp end workers are prone to human errors, the blunt end administrators can add resiliency by looking to build safer processes and systems.  Compounding this error was the fact that organs and tissues are regulated by separate agencies.  Tissue banks are overseen by the FDA and Organs by the Health Resources and Services Administration (Conaboy, 2011). The two have no protocols for sharing information. This is eerily similar to the situation prior to the 911 attacks in that the FBI and the CIA had no protocols for sharing information.

This is a lesson for all in terms of the open sharing of data. We must break down silos in healthcare where they occur and increase opportunity for feedback to those in the system as to the functioning of the system whenever possible. Putting the patient at the center of all we do is a first step in identifying how and where these silos exist.  Human error will occur but monitoring the system and sharing information will create resiliency that will mitigate harm.

Human Error? Nice try Rolling Hills…

In Behavior change, culture, human error on December 23, 2011 at 9:08 am

Article by J. St Amand: Rolling Hills Hospital in Franklin, Tenn., recently refused a lesbian woman the right to visit her partner, reported the Tennessean in a Dec. 21 article. Franklin is located about 20 miles south of downtown Nashville.

The psychiatric hospital went against new federal anti-discrimination laws when Val Burke was not allowed to visit her partner who was in facility’s residential unit. The U.S. Department of Health and Human Services created the rules, which include equal visitation and representation rights, in September.

It was human error,” said Richard Bangert, chief executive officer of Rolling Hills. “They made a mistake. When I learned of it, I immediately met with my staff on Monday. We immediately made the change in terms of making sure that our policy was very clear.”

Bangert plans to apologize to Burke

While it is nice to see the hospital endeavoring to comply with Federal regulations, this was not a case of HUMAN ERROR. Does labeling this as human error contribute to our understanding of it? This is another incident of blame and train. “we met with the staff and made sure our policy was clear.” Is the spirit of the policy “DON’T discriminate against federally protected groups?” Read the rest of this entry »


In human error, Patient Safety, Safety climate on September 25, 2011 at 8:00 am

Hand Hygiene?
Yes, but so much more. Please view this graphic entitled “Hospital Hazards” at Mark Graban’s Lean blog.

Some highlights:
“You are 33,000 times more likely to die from a hospital error than from a plane crash.”
“Mistakes in hospitals cost the US $17 billion each year.”
“Fifty percent of Doctors neckties have been found to harbor dangerous pathogens.”

Can’t we fix this?

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