To Err is Human is a most appropriate title for the Institute of Medicine report released in 1999 on initiatives to improve our healthcare system1.  It is within our human nature to commit errors, but errors in medicine, not unlike errors in flight, are unacceptable.  The aviation industry has taken a stance that zero errors is the only acceptable statistic; they have created a culture in which people are eager to report an error to prevent it from happening again and save lives2.  They have recognized that, in their industry, if they do not fix errors, people die.  Why is healthcare slow to develop the same mindset?  The airline industry experienced a total of 898 passenger deaths in 2015 in the entire world, but in the US alone, experts estimate approximately 250,000 deaths are due to medical error each year 3,4.  These are alarming statistics.

Hospitals have ways to report medical errors and near misses, however, these errors are rarely reported.  Reasons for not reporting medical errors range from the perception of being incompetent to the fear of job loss.  There is also an unwritten “brotherhood” of sorts within the medical community where one medical professional is not likely to report an error that another medical professional makes.  Therefore, something must change, otherwise we are no longer doing what the healthcare community is there to do … save lives.

The only way to encourage medical errors and near misses being reported is to create a non-punitive culture.  A few system-wide frameworks are available to assist healthcare organizations with this task.  An example is the Communication and Optimal Resolution, or CANDOR tool, provided by the Agency for Healthcare Research and Quality 5.  The goals for this, and the other frameworks, are: the establishment of a non-punitive atmosphere where any employee can report the error, an investigation into the cause of the error, and the establishment of a process to ensure the error is not repeated.  While this is a facility-wide framework where diagnostic errors as well as other types of errors can be reported, there are things that can be implemented within your own laboratory.

  1. Employees should feel safe reporting errors.  If there is a perception that they will be punished or receive maltreatment due to the reporting, errors will continue to go unreported.
  2. Determine the root-cause of the error.  It may seem easy to lay blame, but is there an underlying problem that caused the error?  Was there more than one error that took place?
  3. Utilize a group or committee to determine the best way to ensure that the error doesn’t occur again.  Having different points of view is important to develop a feasible solution.  Is additional staff training needed? Is there a process control that could be instituted, such as an LIS hard stop, to ensure that something is addressed?
  4. Monitor specifically for that error.  You do not know if your corrective action worked in preventing the error from occurring again if you are not monitoring specifically for it.
  5. Document, Document, Document.  When processes change within the facility, new errors may occur, or former errors may recur.  Having the documentation of each of the above steps not only meets your regulatory requirements, but aids in determining what needs to be addressed as the new process is put in place, to prevent a previous error recurrence.

The most important of the above steps is the first one.  The entire process of error detection relies on employees feeling safe in reporting them.  Open the lines of communication with your employees to find out why they may not report errors.  There are likely specific concerns that can be addressed either within the laboratory or within your facility to ensure your employees feel safe in reporting errors.  As an industry we know that medical errors, even related to laboratory testing, will occur; we are only human.  However, we cannot move towards “zero errors” if we don’t know where or when they are occurring.  Creating a non-punitive culture for error reporting is imperative to save lives.

 

References:

  1. Institute of Medicine. To Err is Human. 1999. http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf
  2. Tangirala S, Ramanujam R. Role of fairness perceptions in voluntary error reporting: a conceptual framework. FAA paper 2004-01-001. https://www.faa.gov/about/initiatives/maintenance_hf/library/documents/media/human_factors_maintenance/role_of_fairness_perceptions_in_voluntary_error_reporting.a_conceptual_framework.pdf
  3. Makary Martin A, Daniel Michael. Medical error—the third leading cause of death in the US  2016. 353:i2139.
  4. Aircraft Crash Record Office. Statistics Archives – 2015. http://www.baaa-acro.com/general-statistics/death-rate-per-year/
  5. Agency for Healthcare Research and Quality. Communication and Optimal Resolution (CANDOR) Toolkit. May 2016. https://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/candor/introduction.html

About The Author

Brandy Gunsolus is currently the Director of Laboratory Services at Claiborne Memorial Medical Center in Homer, Louisiana. She has a BS degree in Chemistry from Southeastern Louisiana University, a BS degree in Clinical Laboratory Science from Louisiana State University Health Sciences Center – New Orleans, a MS degree in Clinical Laboratory Science from Rutgers University, and has nearly completed the Advanced Practice Doctorate in Clinical Laboratory Science degree program also at Rutgers University. Her research interests are in improving patient safety and patient outcomes through laboratory consultation.