Expert Says Medical Mistakes Can Be Eliminated by Designing Failure Into Medical Processes

ROME, Ga. -- Purposefully designing failure into healthcare processes might be the surprising answer to preventing many medical errors, according to mistake-proofing expert John Grout, the David C. Garrett Jr. associate professor of business administration at Berry College, Rome, Ga.

In the July 2003 issue of the Joint Commission Journal of Quality and Safety, published by the nation's predominant healthcare standards-setting and accrediting body, the Joint Commission on Accreditation of Healthcare Organizations, Grout proposes a new approach to making healthcare processes more resistant to the tendencies of human beings to make mistakes. In short, Grout suggests that healthcare providers design medical processes to fail benignly before patient injuries occur rather than building in additional, often costly, checks and redundancies.

"Medical mistakes, which kill tens of thousands of Americans each year, too often are caused by healthcare workers simply being human," he stated. "They make mistakes that cause failures in the processes used for patient care. Research has shown that no amount of punishment, berating, finger-pointing or guilt will eliminate human error. Regardless of good intentions and extensive training, people will make mistakes -- and some of them will be deadly."

"I suggest that it makes far more sense to design medical systems that make human error irrelevant to outcomes than to create more checks and redundancies for already over-burdened nursing personnel and other healthcare providers," he said. "Increasing nurses' work load or the need for more nurses isn't practical or affordable. Designing processes that fail before a patient is injured may well be both."

Grout uses the example of scalding a patient with too-hot bath water as a harmful process failure that can be caused by human error and prevented by a planned, benign process failure.

"Even if there are checks and redundancies built into the system, it is possible for caregivers to make a variety of errors that lead to scalding," he explained. "It can be as simple as misreading a temperature gauge."

While no water coming from the tap at bath time also is a process failure, he continued, it is inconvenient but not dangerous. In medical terminology, it is benign. Grout suggests that this type of benign failure can be designed into processes, thus preventing patient injury.

"A scald valve could be installed that restricts flow from the tap if the water temperature exceeds a certain level," he stated, "causing the system to fail before the patient is injured even if the caregiver makes a mistake."

This approach follows a conclusion that Grout says was reached long ago in psychology, engineering and quality management: If you want to reduce errors, you have to stop processes from proceeding when they go awry.

Grout's approach utilizes graphic tools called "fault trees" to map processes and identify their potential areas of breakdown -- both dangerous and benign.

"A careful analysis of the fault trees enables an analyst to anticipate how the process will behave after a change is made," he stated. "Process failures that cause harm can be converted into the causes of benign failures."

Grout is among the world's top experts on mistake proofing. He first presented his approach for eliminating medical errors at the Partnership for Patient Safety's international symposium held October 2002 in Washington, D.C. He also presented an invited seminar on reducing medical errors to the leadership of the National Patient Safety Agency in London. He is collaborating with Dr. Harold Kaplan of Columbia University's College of Physicians and Surgeons on reducing errors in the blood transfusion process and spoke at the Workshop on Best Practices for Reducing Transfusion Errors sponsored by the U.S. Food and Drug Administration and the U.S. Agency for Healthcare Research and Quality.

Grout, who earned his doctorate in management science at The Pennsylvania State University, has accumulated an extensive body of knowledge on mistake proofing that is presented at his Web sites, www.mistakeproofing.com and www.campbell.berry.edu/pokayoke . His consulting clients have included divisions of Johnson & Johnson, Bethlehem Steel, General Electric Aircraft Engines, Lockheed Martin, British Aerospace, Kellogg's and Honda.

Source: Berry College