Simple Ways To Prevent Devastating Errors

Over the years, I’ve learned that safety science can be a complex topic.

And you know what I mean…we all hear of the terms high reliability, high reliability organizations, safety culture transformation, just culture, and crew resource management, just to name a few.

Sterile Cockpit Rule

Sterile Cockpit Rule

But making things too difficult impedes adoption and perhaps, this is one reason why we haven’t made the progress that we need to eliminate harmful errors.

The first Institute of Medicine report was released in 1999. That’s over 15 years ago. And yet, many organizations have been unable to substantially improve their error rates. We’ve also learned that it’s not 98,000 deaths per year, but closer to 220,000 to 440,000. So we all still have a lot of work to do.

But the work and the safety tools that we use don’t need to be complicated, complex, or confusing. Those of you who know me, know that I try to keep things simple. I believe that by keeping things simple, anyone can drive huge improvements in a short period of time. This one principle has served me well over my entire career in quality and safety, and I truly believe that it can work for you too!

You see, I’ve seen hundreds of devastating medical errors prevented by some of the most sophisticated, but elegantly simple safety tools.

The Case of Mr. Hosey

Take the case of Mr. Hosey. Mr. Hosey was 73 years old when he was hospitalized following a car accident. At a frail 73, he suffered a collapsed lung from the accident, but he was expected to make a full recovery. He had six grandchildren and several great grandchildren. He was a kind and thoughtful man who loved life and loved making other people laugh. His family was the center of his universe. On the third day of his stay, however, his blood pressure dropped, which caused his kidneys to fail. He passed away several days later.

Why did his blood pressure drop? He was wearing a nitroglycerine patch for his heart failure. The nurse put on a new one at the proper time, but then forgot to remove the old one. Mr. Hosey received too much nitroglycerine, which in turn dropped his blood pressure to damaging levels. Unfortunately, the error was discovered too late.

The Sterile Cockpit Rule

Could this have been prevented? Absolutely! Would that require some complex, complicated process, procedure, or new technology? Not at all. The solution is elegant in its simplicity. In the aviation industry, it’s called a sterile cockpit. During critical times in flight, the pilots cannot be disturbed.

No Interruption Zones

In healthcare, some organizations have adapted this practice by establishing “No Interruption Zones.” What is a good example of a critical task that should not be interrupted? Medication administration is at the top of my list. Interruptions and distractions during this process have been shown to cause catastrophic, even deadly errors. After all, medication errors are the most common medical error we make.

This simple safety practice – NO INTERRUPTION ZONES – during medication administration would have saved Mr. Hosey’s life. Mr. Hosey was my grandfather.

Safety Practices Can Be Simple to Implement!

The lesson is this: Highly effective safety tools can be simple to understand, simple to teach, and even simpler to implement. They can make our organizations and our patients’ care SAFER.

How much safer? Leading organizations have eliminated up to 90% of harmful errors using these tools. Some have eliminated them altogether.

In the coming weeks, I’ll review some of the most effective safety tools from aviation, nuclear power, the Air Force, and other leading healthcare organizations, so that together, we can quickly eliminate many of the most common errors that plague our organizations. I hope you’ll join me.