Mistake-Proofing In Medicine, And In Refrigerators

My refrigerator gave me the idea for this column.

It's an expensive French door model from Sears, the kind with an alarm that goes "beep" after the door is left ajar more than one minute.

Saturday morning, the refrigerator cried for a cleaning. I opened the doors, removed the food and sponged down all the shelves and drawers.

Beep-beep-beep. Beep-beep-beep. Beep-beep-beep.

Good thing I bought the model with the option to turn that annoying sound off, I thought.

Later the next day, something didn't smell right. I had forgotten to turn the alarm back on. If I had, I would have known that the doors hadn't completely closed. Now the ice had melted. The milk was sour. The beer was warm. And the tuna salad would have to go. All because I erroneously deprogrammed my error detection system.

Maybe my refrigerator should have come with another sound—perhaps a bell—that would have alerted me to turn the alert back on? Or better still, maybe refrigerator designers should make any beep deactivation automatically expire after 30 minutes, enough time to clean those shelves.

It's that kind of "mistake-proof" thinking—of course on a much bigger scale—that's now on the minds of designers of healthcare systems, medical devices, and processes.

It certainly must be on the minds of those at Cedars-Sinai Medical Center, where 206 patients received CT brain scans with excess radiation exposure, as well as those officials for GE Healthcare, which manufactured the scanners.

In a letter to the U.S. Food and Drug Administration, Cedars-Sinai CEO Thomas Priselac has suggested some changes in the auto default settings on the scanners, among other design modifications.

GE officials say there's nothing wrong with their machines, but they are undoubtedly thinking of ways to produce additional error-proof features on their next equipment models.

A decade after the Institute of Medicine's famous report, "To Err Is Human," the Agency for Health Research and Quality continues to give mistake-proofing a tremendous amount of attention. This week, an AHRQ official pointed me to an illuminating catalogue containing 155-pages of error-proofing solutions. It is titled "Mistake-Proofing the Design of Health Care Processes."

The document was compiled by John Grout of Berry College in Rome, GA, an associate professor of business administration who has spent the last 12 years thinking about mistakes, and how to program into the process a system failure that will stop the mistake from being made.

"The traditional approach within medicine has been to stress the responsibility of the individual and to encourage the belief that the way to eliminate adverse events is to get individual clinicians to perfect their practices," he writes. "This simplistic approach not only fails to address the important and complex system factors that contribute to the occurrence of adverse events, but also perpetuates a myth of infallibility that is a disservice to clinicians and their patients."

The AHRQ document treats the field of mistake proofing as a scientific pursuit, a way of understanding the essential pathway to the mistake. When are mistakes made? How are mistakes made? And how can health providers lock in systems to prevent mistakes from occurring or from causing harm?

Here are three tips gleaned from the report, but there are hundreds of others.

• Keep items commonly used in plain sight, and remove items that are rarely used, or for which usage requires more skill, preparation, or knowledge.
• Keep standard operating procedures as simple as possible. The more complex the rules and procedures, the more there exists the chance for errors. "Design changes can prevent mistakes by simplifying or clarifying the work environment, making mistakes less likely," the report says.
• Instill a blame-free culture that values accountability, but that allows people to report errors and question processes without fear of retribution or punishment. "A policy of not blaming individuals is very important to enable and facilitate event reporting, which in turn enables mistake-proofing.

The document provides numerous examples of thoughtful mistake-proofing to prevent potentially lethal mistakes.

For example, a prescription filling area at a Norfolk, VA, hospital is marked by red line barrier, indicating a quiet, no interruptions zone for pharmacy workers needing to concentrate in silence. After it was instituted, dispensing medication errors fell by 64%.

A new breed of radiation machine in use at Elbert Memorial Hospital in Georgia can detect the amount of radiation that has penetrated a patient. It automatically terminates exposure when a predetermined level has been reached.

X-ray detectable sponges are increasingly used in surgical settings because when they are left in muscle or fat tissue, they can be easily detected.

A wristband checklist in use at Virginia Mason Medical Center in Seattle uses symbols to show whether heart attack patients have received widely-accepted treatment regimens. Patients can't be discharged until all their wristband records are checked.

And Target has begun using a flat pill bottle that is color-coded and allows flat rather than rounded sides to allow the name of the medication to be more easily read, and so drugs intended for one family member aren't mistakenly taken by another.

The era of the error failure system is here. And clearly more solutions are coming from creative problem solvers.

Maybe they have an idea for a better system to alert when the refrigerator door is left open too long, too.