A Blue Christmas

The message inside the card reads, "Wishing you Christmas peace."

Some things just don't make sense. 

Elvis-as-messiah is one of them. And why a pharmacist will spend Christmas behind bars this year for an on-the-job error is another.

You can read more about Eric Cropp and the circumstances behind the tragic death of a toddler here.

Eric's address in the Cuyahoga County, Ohio jail appears at the bottom of the linked article. I'll be sending him one of the Elvis Christmas cards. There are 17 others in the box. I'll be happy to send one on your behalf, too.

These are a few of my favorite things.....

That's what Julie Andrews sang in the Sound of Music.

But I found them set to a different tune in a patient safety video created by nurse leaders who are DNP candidates. Thanks to Marie Duffy, Nancy Ramos, Cynthia Robotti, Rosita Rodriguez, and Sheryl Slonim for producing this excellent resource!

Why a trick is still a treat

Yesterday morning, I found and posted what I thought was a great video clip, one that seemed to say all the things I am struggling to articulate in an article about healthcare culture and what happens to safety efforts when people don't report errors.

On first pass, the events captured on film jumped out at me, as the old expression "a picture's worth a thousand words" promises they will. An errant SUV, out of control for a split second, crushes two vehicles in the adjacent row of a parking lot. Amazingly, the SUV recovers, backing off of its unlucky neighbors. The video captures a brief latency, during which time one imagines the driver reflecting upon the situation and considering what to do next. Then, the vehicle slinks away, leaving viewers to judge the actions of the driver based upon what we've just seen.

I did. It looked like a vehicular telling of what I recognized, from very early in my career, as unacceptable behavior that might be excused, especially if the driver hadn't made mistakes like this in the past or had a reputation for using the errant vehicle to do good things (like deliver medical supplies to poor people). The owners of the affected vehicles might have had the damage explained in a "collateral" kind of way: These things happen when one chooses to park in a public lot and other disclaimer language, such as what's found in the "limits of liability" fine print on a parking ticket.

Mostly, I saw the lost opportunity to learn what had caused the vehicle to suddenly lose control. How did what appeared to be a routine parking manuever suddenly turn so sour? In the slinking away, I saw the opportunity to acquire information go missing. Information that, if shared, could help others avoid making a similar mistake. Did the driver mistake the brake for the gas pedal? Was he texting at the same time he was trying to park? Or did he wake up that morning and say, "By God, I think I'm going to see if I can dry hump a couple of cars on my way to the dentist?"

But enough about the lessons that could have been learned. There's another, more authentic one for people interested in cultivating a climate that promotes safety, a lesson I figured out when I demanded my son (a new driver) watch the video with me. It turned out that what I thought I had seen didn't make sense in the third or fourth viewing. The superficial "facts" (visible to everyone who views the incriminating video) don't add up. Post-hit, none of the vehicles exhibit any damage and the position of the passive vehicles in the aftermath of the event don't square with the events that one "sees" happening.

So what this video, still a great learning experience, really illustrates is the importance of moving beyond what we believe is readily apparent when investigating the root cause of error events.

People on Twitter are buzzing about the airliner that overshot the Minneapolis-St. Paul airport last week, with tweets like this being the norm:

Too late now but the #NWA188 pilots implausible story is worse for their careers than the likely truth (Zzzzz)

But this approach (that also came in the form of a tweet) shows a better way to get beyond perceptions and beliefs: Missed by 150 miles? And there are cool tools that help front line clinicians become fluent in proactive risk reduction activities, too.

It's fun to speculate about what went wrong when high profile mishaps hit the news cycle or appear to happen right before our eyes. But healthcare leaders who investigate errors and plan risk reduction strategies, benefit from using the same methodologies that FAA and NTSB professionals do.

And that's the safety lesson that really jumps out from the tricky little YouTube video.

Happy Halloween!

How we respond to error

If this is happening where you work (and I don't mean in the parking lot), your patients are not safe.

Participatory Safety

Patient safety is a natural fit with participatory medicine. And not because initiatives that include the word "patient" should seek to involve patients in some nominal, "so glad you could make it" fashion. I don't picture patients manning the Guest Book at the reception when I consider the potential of patients to improve the safety of care.

Patient safety is a scientific discipline, one that seeks to make complex systems work reliably. Systems turn intention into outcome whether you're flying a plane or reconstructing a breast.

Transparency, disclosure, error reporting, and an urge to prevent errors by learning from the mistakes of others are hallmarks of patient safety. People who champion the science of patient safety borrow from cognitive psychology, systems engineering, and human factors, recognizing the inherent fallibility of humans and looking for ways to mitigate the consequences of human error. These are principles patients should know.

Healthcare has suffered from the erroneous perception that good people automatically produce good outcomes. Both patients and providers have had a role in shaping this belief. Since we're all seated at the grown-ups' table, let's get this on it: Healthcare providers are fallible humans. It's not "if" we make mistakes, it's when. What really matters is the consequences of these mistakes, that is, whether they make it to you.

In highly reliable systems, the intended outcome is delivered under both normal circumstances and when conditions destabilize or become hostile. Intended outcomes arise from work processes that build in barriers, redundancies, and lots of opportunities to discover and mitigate errors set in motion before they cause harm. Highly reliable results do not come because the captain of an aircraft is godlike or the engineer at the nuclear power plant was the smartest kid in his class. High reliability comes when competent people:

• perform within a system designed to accomplish the task at hand,
• believe that the system could fail, and
• are empowered to act when a threat, or potential threat, to safety is perceived

It's fair to say that the 100,000 or so unintended deaths due to medical errors and healthcare acquired infections that occur in the US each year disqualifies our industry from being a highly reliable one. So what does participatory healthcare mean for patient safety?

Tons, but here's one of the most obvious: When a patient is seen as a participant in, rather than the object of, care, the system becomes more stable. At its most basic, patient participation adds a valuable redundancy at high stakes junctures of care (as occurs when a patient confirms identity before blood is drawn, verifies the affected area before a biopsy is underway, or asks a provider, "Have you washed your hands?"). Moving into less concrete domains, patients are uniquely positioned to uncover a wide array of errors that have been set in motion.

Here's an example, one that illustrates how patient engagement prevented a serious warfarin overdose:


I know a lot about this case because it happened to me. I derailed a 17.5 mg overdose of warfarin which had passed through a series of high-end automated barriers, including electronic MARs and bedside bar-code medication administration. (You can read the complete story here.)

The take-away lesson is that the warfarin overdose wasn't averted by any special "insider knowledge" of warfarin or the medication use process that I possessed. My participation came in the form of a question ("Do you usually give someone who is close to having a therapeutic INR a big dose of warfarin?"). The nurse's willingness to believe that a concern raised by a patient merited investigation is what allowed the error to surface.

From an engineering standpoint, "patient engagement" takes on value beyond its ability to help people understand a plan of care, decide if it's for them, and manage barriers. Engaged patients add a valuable layer of error detection, one that often does not exist if the patient cannot or will not participate in care (which, by the way, is why advocates and surrogates are such important players in patient safety.)

To make participatory processes work for patient safety, look for opportunities to engage in safety initiatives at the system level. I maintain Florence dot com as a real-time patient safety primer, a place where both patients and providers learn about the science that informs safest practices. Daily tweets that run here point to information and resources that represent best practices, case reports, exemplars, and stumbling blocks. I hope you'll find helpful information here and let me know when you have a safety-sensitive story to share.

Because before you get to the bedside, you want to be sure you're at the table.

Disruptive behavior: Why this dog don't hunt

A hound dog lays in the yard and an old man in overalls sits on the porch. "Excuse me, sir, but does your dog bite?" a jogger asks. The old man looks over his newspaper and replies, "Nope." As soon as the jogger enters the yard, the dog begins snarling and growling, and then attacks the jogger's legs. As the jogger flails around in the yard, he yells, "I thought you said your dog didn't bite!" The old man mutters, "Ain't my dog."

That's disruptive behavior.

Since January 1, 2009 , The Joint Commission has begun addressing hostile behaviors using two new performance expectations:

• The hospital/organization has a code of conduct that defines acceptable and disruptive and inappropriate behaviors.


• Leaders create and implement a process for managing disruptive and inappropriate behaviors.

Disruptive behaviors include the easy-to-recognize ("you-better-duck") kinds as well as passive-aggressive varieties that tend to dog morale, undercutting intention and outcomes. A short, but salient, discussion of disruptive behaviors can be found in "Behaviors that undermine a culture of safety," a Joint Commission Sentinel Event Alert published last summer. The document (and reference list) is chock-full of negative organizational outcomes that can be predicted to arise from disruptive behavior. Irrespective of your stake in the healthcare system, you'll recognize them: medical error; patient dissatisfaction; diminished recruitment and retention; litigation; and increased costs. The document also acknowledges that disruptive behavior is endemic in healthcare settings.

The relationship between disruptive behaviors and highly reliable performance is interesting to me, as are most variables that inform patient safety. I think there are valid reasons, rooted in what's good, right, and just, for people to treat one another with civility and respect. But what "respect," "civility," and "disruptive" look like to large populations of diverse people is subject to cultural nuance, and has always struck me as being exceedingly difficult to operationalize. (I was once a participant in a focus group where someone defined a "nice family meal" as one in which no one stabbed another diner.)

So my engineer's mind wanted to know this about disruptive behavior: "Does managing it lead to better performance?"

Significant barriers prevent this question from being studied in a linear fashion, but work done in commercial aviation over the past 30 years suggests that it does. The analyses of a series of fatal airline crashes in the 1970's led aviation safety experts to understand that human error is causally linked to failures of interpersonal communications, decision making, and leadership. To manage risks associated with human performance, a series of high level communication-oriented behaviors and performance activities, termed Crew Resource Management (CRM), evolved.

Normalizing behaviors within crews has improved the safety of air travel. Malcolm Gladwell tells riveting stories about why and how CRM works in his book Outliers. And a classic scholarly (but easy-to-read) 1999 analysis The Evolution of Crew Resource Management by Helmreich, Merritt, and Wilheim says more and is available online.

Crew resource management is emerging in healthcare with early AHRQ-funded projects now reporting and organizational templates, like TeamSTEPPS now available. The Joint Commission's acknowledgement that disruptive behavior creates breakdowns in the teamwork necessary to deliver safe patient care is an important foundational step in nurturing cultures in which safety is paramount.

Taking on disruptive behavior as the "safety-negative" bully it is, codifies something healthcare providers intuitively know but may have forgotten: If you stab people at the dinner table, they're unlikely to leap to their feet, performing the Heimlich maneuver with efficiency and aplomb when you choke.

The pay-off for investing in natives

The picture of the oak leaf hydrangeas, now in full bloom in my southern garden, says a lot about what you get when you invest in natives.

The thirsty, showy, flashy things I tote home from the sick-plant outlet I patronize can be counted on to demand time and tax my talent. But the natives pretty much do their thing, reliably and predictably. And they always "wow"!

I use Florence dot com, sometimes as a primer, sometimes as a bully pulpit, advancing the idea that front line healthcare providers are natives in the patient safety garden. We should pay them some attention, invest to give them what they need to get started, then be ready to get out of the way.

Most seasoned healthcare professionals grew up in traditions that emphasized the primacy of individual effort over collaborative processes, traditions that neglected science-based approaches for managing the systems that inform performance. (If we wouldn't expect a fight crew to get from New York to Denver by "heading west, young man" why does anyone tolerate a system that tells nurses to deliver medications without more procedural guidance than "follow the 5 Rights"?)

Building reliability into work processes comes more readily when professionals are schooled in human factors and applied cognitive science. Schooling is part of the reason other industries reap the wisdom of the front line in a way that healthcare, as a whole, isn't yet doing. The tradition of "counseling" the last person to touch a process-gone-wrong is hard to give up (apparently it's akin leaving your roots). And healthcare workers often don't recognize, or can't do anything about, the bad soil they're planted in.

So I was happy to receive a tweet yesterday that led me to a partnership between Auburn University and Baptist Health in Montgomery, AL. Synergistic Management and Resource Team (SMART) training will teach highly reliable communication strategies, like those used in the airline industry, to front line healthcare practitioners and students and promote the use of these modalities at the front lines of care. SMART Training combines the tactics of crew resource management, purpose-based decision making, evidence-based practice and simulation.

It's worth noting that the curriculum was developed using the expertise of Auburn's Aviation and Supply Chain Management faculty in collaboration with professionals from Baptist Health's Institute for Patient Safety and Simulation Training. Applying knowledge that comes from studying the root causes of communication snafus to develop strategies that prevent recurrence is more rewarding, but far more difficult, than focusing on "who-didn't-hear-what-right-this-time." Teaching the science behind measures that are often seen by front line clinicians as "compliance-driven" rather than "safety-essential" may help cultivate healthcare's holy grail, the culture of safety.

Turned out it was in the garden all along. Smart. Or is that SMART?

Get ready to cancel the launch!

In Lessons from a Sunken Ship, I recounted the story of a 1628 shipwreck that occurred in the aftermath of a failed stability test, a test result known to at least 30 shipbuilders (who nearly put the Vasa underwater during a preliminary test of seaworthiness) and the ranking military leader who observed the aborted test. Signing off on the launch, the ranking officer lamented the absence of the King, apparently the only person with authority to cancel the launch.

This story lends itself to talking about the dangers of rigid hierarchies, and I'll probably return to it at some point, rigid hierarchies having sunk more than a few ships in healthcare. But the Vasa also illustrates principles about the hierarchy of error and harm prevention:

1. Eliminate or prevent mistakes. A better design would have prevented the Vasa from going down.

2. Make mistakes that have been set in motion visible. The ship did not perform as expected when subjected to simulated sea-like conditions. Not launching a ship with dubious stability would have prevented the Vasa from going down.

3. Mitigating the hazard should a mistake occur. Lifeboats prevented some people on the sinking ship from going down.

4. Education/re-education about how to manage known hazards. Swimming lessons might have helped some people save themselves.

Healthcare has been criticized for the tendency to bottom feed when it comes to risk reduction, meaning that we tend to rely on risk-reduction strategies low on the hierarchy. This doesn't mean that, as individuals, healthcare professionals don't care about risk or don't want things to turn out well. It simply means that we're more likely to select and implement interventions like "review policy" with individuals who make errors than to examine the underlying factors that allowed frontline workers to err. We spend a lot of energy attempting to teach front line clinicians how to save themselves.

So if we got out of the lifeboats and headed north on the risk-reduction hierarchy, how far could we go and what would the consequences be?

Health and healing are complex, and it's fair to say that we're sailing more than a few badly designed ships. 1 in 7 Americas lack healthcare insurance. Healthcare disparities are rampant. Patients are older, sicker, and rounder than they used to be. Our system does not incentivize prevention. A better design would avert many crises. But redesign of healthcare--something that appears to be emerging as a national priority--is outside the locus of control of individual clinicians, irrespective of how often or how nobly we face the consequences of the current bad design.

So how can front line clinicians prevent a poorly designed vessel from sinking? One answer is: embrace processes and procedures that make mistakes set in motion visible. Be able to identify emerging practice changes as the higher-level risk-reduction strategies they are. Get ready to cancel the launch!

A bar-code scan reveals a mismatch between ordered medications and a similarly packaged one in the patient’s drawer: you’ve cancelled a launch. A pre-procedure time-out reveals a site-of-surgery discrepancy: you’ve cancelled a launch. Reading back and verifying a telephone order (insulin 50, five-zero, units sub-cutaneously now) reveals the prescriber on the crackly line said one-five (15), not 50 units of insulin: you’ve cancelled a launch.

Cancelling a launch is not as good as preventing mistakes from occurring. But this approach trumps lifeboats and swimming lessons. Right now, healthcare is adopting, occasionally adapting, risk-reduction strategies from other industries, industries more reliable than ours.

The best risk-reduction strategies, in my opinion, are yet to come. As healthcare workers--bright, caring, and competent individuals—come to understand the principles that drive reliable performance, participate in developing highly-reliable processes, demand these be vigorously applied, and eventually come-of-age in an environment where reliability is the norm, it will no longer be necessary to report preventable adverse health events as aggregate data!

See you there!

Grand Rounds

This week, Leslie is hosting an interesting discussion for Grand Rounds, reflecting on the way life used to be. Since my experience has been that some of the best thinking and most creative solutions to tough problems come from non-linear approaches, I was happy to see how many different ways healthcare bloggers took on the challenge to reflect about change.

And kudos to Leslie for linking all the submissions in such a cohesive way!

I'm in-between posts, writing more about what sunken ships and old Swedes tell us about safety in healthcare systems today. The story of the Vasa, Lessons from a Sunken Ship, and a short analysis is included at Grand Rounds under "The More Things Change, The More They Stay The Same."

Leslie has given me something to think about as I write the follow-up piece to Lessons from a Sunken Ship. She saw my post as calling for regulatory measures to ensure that the wisdom of the frontline is heard. (Something, I'm afraid, likely to cement my husband's darkening opinion about my thought processes.)

I'm actually more interested in ways to influence culture, ways to promote a culture of safety, that are less linear than regulations and standards tend to be. Our "company manners" will only get us so far. I want to be at the table when only the family is home!

Lessons from a Sunken Ship

A thing I’ve begun to enjoy about blogging is that it helps me find memories I might otherwise have forgotten and lets me bring people (and pets) into some discussions that might have meaning for you, too. Thanks to all who have sent kind words about Daisy, our dog who is currently receiving hospice care (and recently debuted as the poster child for safe canine medication practices). It’s been a quiet, medicated morning, and I’ve been tooling around the internet and touching base with my parents as I put the finishing touches on the story about ships, Swedes, and safety that I’m sharing today. I hope you’ll enjoy it!

"Those who cannot learn from history are doomed to repeat it."
- George Santayana

On August 10, 1628, only minutes after setting sail on its maiden voyage, the mightiest warship of its time, loaded with a crew of 150, sunk in the Stockholm harbor. The Vasa had been commissioned by King Gustavus Adolphus, Sweden's monarch, who was engaged in a fight with the Poles at the time and desperate to seat a crown jewel in his armada. It’s a well-established fact that the King repeatedly tinkered with the vessel’s design while simultaneously demanding its rapid completion. But these were not the only reasons the Vasa sunk.

Like all disasters, this one had a host of contributory factors setting up the “perfect storm,” that allowed the mighty warship to sink in the Stockholm harbor on a perfectly beautiful, sunny, summer day. An abbreviated but insightful root cause analysis can be found on the official Vasa website. For people who are interested in how culture influences safety, as I am, lessons gleaned from the Vasa are particularly valuable.

It’s relatively easy to see how untested innovation, production pressures, and loss of key leadership contributed to the Vasa’s disastrous voyage. But what's really interesting to me is the Vasa’s failed stability test: In the days before the tragic voyage, the ship had undergone a preliminary test of seaworthiness using the stability testing standards of the day. This involved having a gaggle of men from the shipyard, in this case about 30, run back and forth across the ship’s deck while the ship remained moored. The Vasa’s stability test was halted after just three runs-- long before a satisfactory result was obtained--to prevent the ship from capsizing at the dock.

Nothing further was done to improve the Vasa’s stability before the ship set sail days later.

This sequence of events means that in the interval between the failed test and the maiden voyage, there were at least 30 rank-and-file shipbuilders who knew, who had to have known, that the ship was destined to sink. Do you wonder what they were saying to each other?

I think this particular piece of information captured my imagination when I toured the Vasa Museum several years ago because I know a little something about Swedish sensibilities, having been raised by a first generation Swedish-American whose family flipped back and forth between Sweden and the U.S. in the early 1900’s. Three of my grandparents emigrated from Sweden, and I was born in a small town with a large sub-population of Swedish immigrants. We’re private people, not given to share unsolicited advice (although my cousin once observed that if you sought my father’s advice, he would provide such a detailed explanation that even a novice could fix a Corvair). I joke that if my father asks, “How’s that working out for you?” you’re likely doing something that could cost you a finger.

I don’t know if my father’s sensibilities speak to the culture in the Stockholm shipyard in the 1600’s, and frankly, it probably doesn’t matter. What does matter, and still matters today, is that the Vasa sunk in part because there was no mechanism in place, no recognized, endorsed, or welcomed way, for critical information known by line managers and workers to be heard. My father will help you out, lending his considerable knowledge, time, and skills most generously, but you have to let him know you want to hear from him.

In 2007 (that's 379 years after the Vasa sunk, according to the calculator app in my iPhone), researchers studying how to best identify and respond to healthcare defects giving rise to the epidemic of adverse events that confront us today observed,

“There are many sources to identify defects, including patient safety reporting systems, morbidity and mortality conferences, sentinel events, liability claims, and perhaps most powerfully, asking staff how they think the next patient will be harmed.”1

This concept ain’t an iPhone, folks. Just ask my Dad.

Coming next: Later is better than never (more lessons from the Vasa).

1 Berenholtz, B. & Pronovost, P. (2007). Monitoring patient safety. Critical Care Clinics, 23, 659-673.

"Here's Your Sign" is not a High-End Risk-Reduction Strategy. Go Figure.

I live in the southern part of the U.S., and, like most of my friends, I like Bill Engvall, one of the funny men on the Blue Collar Comedy tour. Larry the Cable Guy, not so much, but I really think Bill Engvall is funny. If you don't know who he is, here's one of Engvall's jokes (and a link that takes you to the lyrical version of "Here's Your Sign"):

A couple of months ago I went fishing with a buddy of mine, and as we pulled his boat into the dock, I lifted up this big 'ole stringer of bass.

This idiot on the dock goes, "Hey, y'all catch all them fish?"

"Nope. Talked 'em into giving up."

I like Bill Engvall’s take on the human condition. It helps me make it through the Walmart. But when I go to work, I try to leave Bill behind. Here’s why:

In Chipping Away at Risk, I talked about how professional standards in other industries call for the use of the highest feasible strategies to manage predictable risks, and noted that similar thought processes are not yet considered "the norm" in the healthcare culture. In healthcare, it’s easy to draw from our duty-oriented traditions, falling back on what an “A player” wants to do on a good day rather than what a “B player” produces on an average day. (We will not discuss "C players" today.) But Human Factors research tells us that different, more reliable processes are needed to manage predictable risks that arise when people, processes, and equipment converge: "Hey, y'all catch all them fish?"

So here’s a user-friendly list of risk reduction strategies, one that’s widely used by the safety analysts at the Institute for Safe Medication Practices. The strongest error-reduction strategies are listed first, with the less effective options lower on the list:

• Fail-safes & Constraints
• Forcing functions
• Automation & Computerization
• Standardization
• Redundancies
• Reminders & Checklists
• Rules & Policies
• Education & Information
• Suggestions to be more careful or vigilant

And three examples showing how these principles look “on the job”:

1. A patient care unit where the primary fall-prevention intervention involves nursing personnel “keeping a close eye on patients at-risk to fall ” is using a less reliable fall-reduction plan than a unit where nursing vigilance is augmented by standard measures (such as the opportunity to use the bathroom every two hours). This can be predicted because scheduled opportunities to use the bathroom standardizes an intervention while “keep a close eye on them” relies on personal vigilance, a much weaker risk-reduction strategy.
2. A neonatal unit that has a policy stating only 10 units/mL heparin will be stocked in the unit’s automated dispensing cabinet (ADC) has a less reliable risk-reduction plan in place than a neonatal unit where heparin products undergo bar-code scanning prior to delivery to the unit and prior to being prepared for a given patient. Bar-coding is an automated risk-reduction strategy with reliability that trumps both policy statements and the accuracy of humans when “reading the label.”
3. Port-free epidural tubing, especially those with distinguishing colors and features, makes patients safer than using standard IV tubing because the absence of a port is a constraint that can prevent inadvertent administration of parenteral drugs to the patient’s CNS, a tragic occurence that regularly happens when well-educated clinicians become distracted.

I hope the rank order of risk reduction strategies and the clinical examples give you something useful to consider about mitigating on-the-job risks and how to respond when an error occurs.

Stay safe, find some time to fish, and come back soon!

LASA: It's Not Just Another Bad Abbreviation

I'm talking about errors associated with look-alike, sound-alike (LASA) drug names today because LASA problems offer concrete examples of risk points that dog clinicians involved in the medication use system. (For purposes of this discussion, my quick-and-dirty working definition of a risk point is "any underlying factor that predisposes to error.")

In the last post, I referred to new research confirming something you probably already know: healthcare professionals struggle with reporting mistakes, and we struggle with the fact that we are fallible when we're involved in errors. When people believe that “bad people” or “good people having a bad day” are individually responsible for most medical errors, it’s easy to see why reporting error and reconciling feelings of personal responsibility become burdensome. But reporting and reconciling become easier when you look for solutions that improve the nature of the process, not the nature of the people. Face it, we’re all going to have a bad day once in awhile, and, unfortunately, not all people are good.

(I recently spent a year as the Safe Medication Management fellow at the Institute for Safe Medication Practices. But, as you can read in my last post, I was tripped up by look-alike packaging of hand sanitizer and hand soap a few weeks back, proving yet again that “knowledge” does not trump “process.”)

Human error is typically a by-product of the systems we practice in, and with LASA errors, it’s hard to miss the risk points. The category of LASA-related errors exists because, frankly, drug names are often similar to one another. It's easy to see how words and phrases like "oxycodone and oxycontin" and "Novolog Mix 70/30 and Novolin 70/30" could be mixed up. Similarities like these regularly give rise to confusion, and yes, error. We see look-alike, sound-alike word confusion in other settings all the time: if you haven't seen "your" erroneously substituted for "you're" recently, you're reading better things than I am! But when word mix-ups have the potential to give rise to medication errors, stronger processes that guard against selecting the wrong one need to be in place.

Next time, I'll share data and some easy-to-access resources for preventing LASA errors. Maybe you have an example of a look-alike or sound-alike error to share? (If you do, tell your story in the “comments,” omitting identifying information. On Florence dot com we neither offer medical advice nor violate HIPAA regulations.)

So, good people, stay safe and come back soon!

A Picture's Worth One Thousand Words

When I made "patient safety" my business, I stepped away from specialty practice in intrapartum and high-risk antepartum nursing care, a decision that is sometimes difficult to explain. Last week, I wrote about how the perception of patient safety as a warm, fuzzy, intention-based goal can get in the way of actionable things--like workflow analysis, process mapping, and harnessing the power of technology--to deliver efficiencies, reliability, and economies of scale.

Another aspect of the career shift has been the risk of becoming a "glass half-empty" kind of girl, a perpetual naysayer who tells earnest, well-intended, and increasingly cash-strapped healthcare professionals, "Really folks, this is simply not enough. Have you forgotten that medical errors are the 8th leading cause of death in the U.S?” Last week, Oprah helped me out, hosting the Quaids and reminding us that "every year in the United States, more people die from medical mistakes than from breast cancer, AIDS and car accidents…combined. It's a major, major health issue that will touch almost every single American at one point in our lives."

I’m not a person who sees the glass is half-empty, nor am I an apologist. So I’ll share here what’s helping me to reconcile the irrefutable mismatch between intention and outcome that is healthcare today.

First, it may be helpful to simply acknowledge that errors are very common in healthcare. So common, in fact, that the Agency for Healthcare Quality and Research has endorsed a taxonomy to describe and categorize them. While this may be shocking at first glance, it’s actually good news: Using a specific nomenclature to describe events and categorize them is an epidemiologic approach to problem solving. Taxonomies are used in the study of other vexing problems (like breast cancer, AIDS, and car accidents). So, it’s reasonable to expect that similar processes would be used to diminish the incidence of our problem: medical errors.

While the charge “First, do no harm,” may resonate with many clinicians, this is a goal statement, not a process map. “Just Do It!” just doesn’t, well, do it when it comes to solving significant threats to health.

If you visit AHRQ’s Patient Safety Network, you’ll find the error taxonomy is searchable by a variety of categories (for example, “care setting”; “clinical area”; “type of error”). The one I use most often is “approach to patient safety” because this query lets me “connect the dots,” seeing how specific strategies (like “patient hand-offs”) are seated within larger motherships (like “Communication Improvement”). The taxonomy maps the current “method to the madness,” and leaves room for new ideas. (You’ll notice that the labels I apply to each post at Florence dot com often include key words from the patient safety taxonomy.)

Second, everyone makes mistakes. We may not mean to, but we do. There is a strong body of evidence suggesting that in the aftermath of an error, healthcare professionals struggle with what actions to take and how to reconcile their feelings about having been involved in an error. And a recent study in the Journal of Patient Safety suggests frontline clinicians remain conflicted about disclosing, discussing, and reporting error, despite efforts to increase transparency, promote reporting, and look at error in context. (If I were to apply a label to the discussion right now, I’d choose: culture of safety.)

It may be easier to start talking about errors that happen in healthcare settings by talking about errors that didn’t. Take a look at the photo below and see if you can guess what happened when I cooked breakfast at my church a few weeks back.

Yes, I washed my hand with a hand sanitizer product intended to be used without water, an activity that neither cleansed nor sanitized my hands.

Obviously, I didn’t read the label. A look at my kitchen sink will help you see why:

(In case you can't read the label--something that's difficult to do even in here in my kitchen--the little-bitty font just above the green leaves says, "Hand Soap.")

Two distinct products that share similar packaging, similar color, and similar placement: an error-prone set-up in the community. And an error-prone set-up at work.

This is not to say that I think the consequences of mixing up products in a community setting and the consequences of mixing up products (particularly medications or cleaning agents) while on-the-job are equivalent. In fact, it’s precisely because the risk of harm is so much greater when error occurs in a healthcare setting that processes on-the-job need to be far more robust than what we typically use at home.

I hope you’ll come back as this discussion evolves! (Feel free to use the comment section to share your thoughts with me and with each other.) And in the meantime, I hope you'll stay safe!

Next time: LASA: It’s not just another bad abbreviation.