Do People Or Processes Cause Healthcare Mistakes?

“94% of all failure is a result of the system… not people.’ W. Edwards Deming

System errors in healthcare are part of the culture – ‘that’s the way it’s always been done’.

We should treat healthcare systems the way we treat patients. We should assume that apparently diverse problems are related – that is, apply Occam’s Razor. Currently, healthcare system problems remain partially treated at best, and at worst new ‘treatments’ create new problems elsewhere. This contributes to the > 20% waste in healthcare spending that is seen worldwide (OECD 2017).

Why don’t we take a holistic view to healthcare systems? One important reason is that usually very few individuals are affected in each healthcare system problem, with relatively small individual consequences or expense. However, multiple small problems generate massive expense to society – monetary, social and loss of productivity.

Contrast healthcare with a high-risk industry such as oil and gas. Here a small mistake tends to create a large-scale disaster with many casualties, a highly visible environmental impact and an expensive cleanup and compensation. The industry has a different mindset as a result.

Organisational attitude to risk and error was described by Hudson in 2003, with five stages of increasing trust and awareness. These stages can be seen in the Figure:

Hudson levels

We’ve all seen these stages in healthcare. If you’d like to delve deeper, the New York surgeon Atul Gawande’s 2009 book The Checklist Manifesto makes interesting reading with personal and the historical perspectives on healthcare reliability.

A common flaw in healthcare thinking is that mistakes, while infrequent, are inevitable. At the start of my career mistakes were regarded commonly as ‘one-offs’, with the incorrect assumption that ‘they won’t happen again, so don’t worry about it’. Hudon’s Stage I – sound familiar?

Later in my career, safety was regarded as important and ‘a lot would get done every time there was a problem’. This is an improvement, however is still a reactive (rather than proactive) organisational attitude to risk and error, one step ahead of seeing mistakes as ‘one-offs’ – Hudson’s Stage II.

Currently, most of healthcare has systems in place to manage hazards – Hudson’s ‘Stage III’ reliability. Champions of this revolution have been individuals such as Gawande, organisations such as the OECD, the Institute for Healthcare Improvement (IHI), the World Health Organisation (WHO), and the International Society for Quality in Healthcare (ISQH).

So what can be done at an enterprise level to reduce system errors? The complexity of healthcare delivery and enormous variation in size of facilities and mix of operations that they perform means that a ‘one size fits all’ approach is likely to fail.

An approach is required that minimises overlooking the essential elements of a process, while allowing a degree of freedom for adaptation at the local level. Considering improvements in terms of:

  1. The user experience,
  2. Healthcare quality and
  3. Efficiency of delivery

helps reduce unintended consequences of change, which increases acceptance, implementation and success.

Supporting humans on repetitive processes with information technology should help to free healthcare workers from drudgery that takes them away from patient contact – the main reason that most people get in to healthcare. Unfortunately many IT projects turn inefficient paper processes into inefficient electronic processes, resulting in more screen time rather than more human-time.

Successful IT projects look for overlap and commonalities where IT can connect the dots and bridge the gaps. I’m always on the lookout for such providers, especially if they’ve been created to solve inefficiencies in the Australian context. Some providers that I work with are listed below.

If you know of any companies improving the user experience alongside efficiency and quality, please reach out!
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Paid Advisor to Surgical Order (SOx).

  • Streamline Hospital Operations: efficient, risk-free theatre scheduling – simplify the logistics of planning and delivering a theatre list.
  • Manage Inventory & Orders: Save time and money by managing stock with real-time updates for order status, billable items and expiring stock.
  • Connect Practices, Hospitals and Suppliers: Surgeons’ Lists, Orders, and Preferences are all simplified and synchronised directly with Hospitals & Suppliers.
Advisor to Atidia. 

Optimising patient care to improve patient outcomes and reduce costs, with:

  • Digital Questionnaires: Conveniently and quickly gather essential background information from patients directly using a dynamic, multi-language, mobile-friendly app.
  • Essential Risk Models: Automatically calculate baseline risk analyses such as BMI and ASA score. High risk conditions and medication issues are flagged.
  • Smart protocols & safety: Automatically suggest patient, medication and test advice based on institution and best practice protocols. Make preoperative advice easy, repeatable and consistent.
  • Anaesthetic Summary: Beautifully presented clinically relevant information, allowing for actionable insights, life-saving preparation and interventions.
  • Quick & Easy Integration: Standalone or light integration with a range of EHR systems, either on-premise or in-cloud.


Pro-bono Advisory Work:

Calvary Adelaide Hospital:

  • Medical Advisory Committee (MAC)
  • Medication Safety Committee
  • Perioperative Working Group

Memorial Hospital: Paediatric Committee

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