By Robert J. Latino, CEO Reliability Center Inc. [22 pages .pdf]
Abstract: Risky Business – Winter Newsletter 2018
My role as a Root Cause Analysis (RCA) practitioner, educator, author and software designer in the heavy manufacturing industries for the past 32 years played an important part of my perspective when researching the applicability of RCA in the healthcare field. I began my journey into the exploration of the healthcare culture nearly 20 years ago, and it has been an enlightening experience to say the least. In this paper I will seek to draw many parallels between the manufacturing/ process and healthcare cultures, with an emphasis on dramatically increasing patient safety in the short-term. Keeping in mind the entire time my primary experience in healthcare has been as a patient!
A Manufacturing Industry Outsider’s Journey into the Healthcare Culture
Let me start this paper off with a comment about healthcare – “Based on my past experiences, I believe that people who work in the healthcare field are one of the most committed groups to their profession that I have had the privilege to work with”. I make this statement up front, because many of the observations that I will outline in this paper, make give the misperception the above statement is not true.
I come from a field in the manufacturing industries called Reliability Engineering (RE). This field of engineering was pioneered in chemical manufacturing by Charles J. Latino while he was the founder and Director of the Reliability Center for AlliedSignal Corporation (Now
Honeywell) in 1972. Reliability Engineering is a field that focuses on equipment, process and human reliability of any ‘system’ (input, transformation, and output). One of the many methods and tools that we developed while in this group was the application of Root Cause Analysis (RCA) and Opportunity Analysis (OA) to manufacturing systems and processes.
Outsider: The Signals Were Stacking Up in Healthcare
In 1998, it came to our attention that some studies that were coming out in the healthcare sector, would not be endearing to their ability to increase patient safety. We also followed pending legislation that showed a trend towards efforts to reduce medical error. In short, the writing was on the wall that the healthcare industry would soon become “under the microscope” for excessive medical errors and hence increase the patient’s risk of unnecessary harm. This tension in healthcare, at the time, peaked with the release of the IOM report in 1999 indicating that between 44,000 – 98,000 people are killed a year by medical error. Now the public uproar would ensue and would expose a worldwide epidemic of medical error. Since that iconic report in 1999, numerous subsequent reports have indicated the number of annual deaths due to medical error in the U.S. has exceeded 440,000.
As an ‘outsider’ to this healthcare sector, such numbers are appalling. Deaths by medical error are now the third leading cause of death for all Americans behind heart disease and cancer. I was even more frustrated, bordering on angry, when I found out in the fine print, the IOM report only considered “errors of commission”. Errors of commission are when someone takes an inappropriate action in handling a patient’s care and the patient ends up worse than they were before as a result of the error. My point here is that ‘errors of omission’ were not in the report. Errors of omission are where someone should have taken action and did not. For instance, a patient comes into the emergency with some symptoms that are not assessed/prioritized properly by triage. As a result, they wait in the waiting room for an extended period of time and suffer a heart attack, a seizure, or any other consequence of not being seen in a timely manner. I would personally see the number of deaths by errors of omission as being a significant multiple of those deaths by acts of commission. I have not met anyone in the healthcare profession who does not believe the IOM report on deaths was grossly conservative.
The Paradigm of Patient Safety
This is the point where my ‘outsider’s view’ of the hospital being a safe haven, turned to my paradigm about healthcare to ‘avoid getting hurt at all costs so that I do not have to run the risk of being admitted to a hospital’. I suspect that most Americans are like I was, they see going to the hospital as a place they can entrust their health and welfare in the professionals’ hands. Many healthcare professionals I have met throughout the last twenty years, indicated they would never leave a loved one alone for a minute in a hospital. They said everything must be watched and questioned regarding their loved one’s care… to be vigilant.
I have been attending numerous healthcare conferences over the years and the undeniable focus is on Patient Safety. I listen to very talented and esteemed speakers tell of their efforts to increase Patient Safety at their respective hospitals. During this time, I am thinking to myself, “If Patient Safety is only becoming the focus now, what was the focus before?” From my perspective as a patient, I would have thought Patient Safety was always the focus in healthcare.