The only real mistake is the one from which we learn nothing
Written by Tom Varghese
In healthcare, mistakes can have consequences that can vary from losing time to affecting patient outcomes. Without a doubt, healthcare presents special challenges where judgment and individuality are involved.
Between 1 July 2018 and 30 June 2019, health and disability service providers in NZ reported a total of 916 adverse events to the Health Quality & Safety Commission, with reports coming from DHBs, ambulance services, private hospitals and primary care providers. 260 of these events related to clinical processes and procedures, 232 were related to behavioural events and 12 were related to clinical administration. Contributory factors included staff workload, failure in communication systems, erroneous use of equipment and supplies and incorrect management of staff and staffing levels.
Poka-yoke (pronounced poh-kah-yoh-keh) is Japanese technique that is most often translated as “mistake-proofing”. Poka-yoke processes can be found in many instances in healthcare. Using the lean manufacturing mistake-proofing technique of poka-yoke, manufacturers of medical devices have designed safety features that reduce the possibility of a serious error occurring. Though they have not been 100% effective, these poka-yoke techniques have gone a long way in preventing serious injury, misdiagnosis, and death of patients.
Scanning wristbands and vocally confirming the name of the patient before surgery prevents mix-ups, alerts in prescription software prevent bad drug combinations, automatic wheelchair brakes, and an alarm that goes off when a hospital bed is tilted to the wrong angle are examples. The key is to prevent mistakes before they are made.
Mistake proofing provides four different approaches to designing processes that tend to reduce human error. Design mistake prevention and detection into the process, design the process to fail safely and design a work environment that prevents errors. The ideal result is when the poka-yoke fits seamlessly into the workflow, or even making the workflow better, benefiting everyone involved.
Health services are complex systems with many autonomous yet interdependent components. The ability to adapt and vary responses depending on the situation allows effective care to be delivered on a day-to-day basis.
Quality improvement methodologies, including adverse event reviews should not sit in isolation to be applied in order to achieve a state of safety but should be part of ‘everybody’s business’ in the provision of safe healthcare, all of the time. A culture based on trust and openness gives the workforce the confidence to share, to be supported and to enhance the capability to learn in often new and different ways. Supporting staff with high-level governance and strategy, while allowing them to make decisions, is an effective strategy for managing complex systems.
