Proactive Resolution of Near-Miss Problems

In addition to FMEA brainstorming, hospitals must react appropriately to near misses, turning each problem into an opportunity to drive process improvements that prevent that same error from happening again. One foreseeable hospital process defect is administering an incorrect intravenous drip to a patient. Potential risks include giving the wrong dose or the wrong medication. One study estimated an error was made in 49% of intravenous preparations and administrations.[43] While there are numerous checks and rechecks of intravenous bags during the intravenous production process in the pharmacy, errors still get through to the point at which a nurse is poised potentially to administer the wrong drug. The fact that all errors are not caught in the pharmacy is evidence of how 100% inspection is not 100% effective, even with multiple successive inspections. Think about a case in which a nurse properly inspects the medication and finds an error at that last stage of the value stream of the intravenous bag through the hospital. In a perfectly error-proofed process, this should never happen. The nurse's reaction and the reaction of the organizationto such a near miss is crucial. A non-Lean organization might consider the nurse catching the error by the pharmacy as proof that the system worked. People might ask, "What is the problem? The patient was not harmed." Catching the error before the patient was harmed is certainly a positive event, but it should be considered the sign of a weak process that allowed the error to get as far as it did. The next time, the nurse might not catch the error in time. A common workaround would be for the nurse to correct the immediate problem, for example, by going and getting the right dose. The real problem is not solved, however, as the error is likely to be repeated if the root cause of the underlying error is not solved. The nurse might say "We were lucky. Let's hope that doesn't happen again." There might be a temptation not to report the problem or to cover up the near miss. Employees, including the nurse, might not have the time to follow up properly or conduct root cause problem-solving analysis because of overwork and the need to move on to caring for other patients. The error will certainly happen again, at some point, because of the same systemic cause. In the McClinton case, let us assume that the syringe was being filled with the wrong solution, but another person in the room saw the error and called it out. This would-be "near miss" would have been as much of an opportunity to improve the process and to prevent any harm to patients. In a Lean culture, we need a number of conditions to ensure that the root cause is solved, including An environment in which employees are encouraged to stop and solve problems when they are found (or as soon as possible) Available time for root cause problem solving (freed up through earlier waste reduction) A blame-free environment in which employees are not punished for raising problems to the surface for root cause problem solving

Managers who take the time to help resolve issues with or for employees as they are raised Cross-functional cooperation to work together on problems that are generated upstream but create waste for a downstream function or department

Figure 7.3: The Alcoa safety pyramid. (Adapted from Woletz and Alcoa.)
[43]

Taxis, K., and N. Barber, "Ethnographic Study of Incidence and Severity of Intravenous Drug Errors," British Medical Journal, 2003, 326: 684.