What Might Happen in an Organization Not Failure-Ready?

By Larry Ozeran MD, President, Clinical Informatics Inc.

HIMSS core objective as an organization is to improve healthcare quality and patient safety with information technology. As hospitals and providers work to implement electronic health records and other IT and management systems, HIMSS is launching a blog series on health IT and patient safety to help providers and hospitals identify potential risks to patient safety that have resulted from problems with EHR implementations and mitigate those risks through proactive measures.

The primary reason that the scenario discussed in our last blog  quickly and cheaply is because the culture of the organization accepts that mistakes sometimes happen. Mistakes are rarely caused by a single point of failure. In this case study, better choices could have been made by the software vendor, as well as by the hospital during the selection process, the training, the software tuning and subsequent management.

Let us work backwards. The ED staff noticed that medications would disappear when entering new medications in the same class. The IT staff made the configuration change. The process for IT requests went through at least one medical staff committee before IT was authorized to implement a solution. The configuration option was requested by a hospitalist who was repeatedly frustrated about having to actively delete the old beta blocker when entering a new one. The software vendor permitted this configuration option.

  1. Is there one person to blame?
  2. Could one or two interventions completely avoid this risk?

The author would suggest that the answer to both questions is “no.”

Healthcare operations are complicated. In general, there will always be risks like this one. No matter how diligent your organization is, small subtleties managed by different pockets of your organization and your vendor will prevent any one person from understanding all of the big picture implications. Let us consider what a failure-averse organization might have done differently and how the outcome might also be different.

Imagine an organization where the CEO is “results driven.” Perform well or lose your job. Make a mistake and be disciplined, publicly. Make a second mistake, and you’re out of a job. The CEO believes that patients are too important to tolerate mistakes by staff. Anyone who shows they are incompetent shouldn’t be around “our” patients. Training is a waste of money. People either know what to do or they need to learn it someplace else. We only hire “the best.”

In this failure-averse culture, would you step forward, if you found a problem or would you work around the problem? Most often, staff find workarounds rather than confront management with a problem for which they might be blamed, even if they are only the messenger.

In the case study previously described, the ED staff notice the same problem. Under failure-averse management, rather than be blamed for erasing the existing medication, the ED staff simply adopt an unstated policy of printing the medication list, comparing the list to the new list after they have completed their entries, and then, adding back any medications that were deleted. Problem solved, right?

Unfortunately, no. This creates a problem when:

  1. Training new ED staff who may not learn about this workaround and are unaware that the software deletes some medications;
  2. Any of the workaround steps are skipped or forgotten; and
  3. By making it look like the ED staff entered a new medication rather than it coming directly from the pharmacy as an existing medication.

As a result, at discharge, the medication is not continued. Only months later, when a patient is not restarted on his ACE inhibitor and is readmitted for a hypertensive crisis, does the problem first come to light. At this point, trying to untangle the root cause is much more difficult.

To be a failure-ready organization and identify problems early when they are easiest, cheapest, and most quickly resolved:

Promote a supportive culture – one that ensures that:
-you are actively listening to your users,
-you do not shoot the messenger, and
-problems are shared shortly after they are observed.

Periodically ask what is going wrong:
-Consider having monthly or bimonthly meetings dedicated to openly discussing problems, then prioritize solving them.
-Have an anonymous suggestion box and act on the suggestions publicly.

Require accountability.                                                                                                            –While everyone makes mistakes sometimes, that does not mean everyone gets a free pass to do what they want.

By all means discipline and, if necessary, dismiss the staff person who: fails to learn from coaching and training, cannot perform the basic requirements of the job, disregards the value of human life, or is unable to work as a supportive team member.

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