8. Complexity

Recently a tragic mix up where oxygen tubing was connected to a urinary catheter resulted in the death  of ex-Socceroo Steve Herczeg (see here).

‘How can anyone make this mistake?’

Unfortunately events like this occur regularly – we often only here of them via the media – our error report systems lacking transparency (see here).

This link from the FDA (see here) documents numerous similar mis-connections.

Through understanding why these events occur we may be able to prevent them.

‘The modern intensive care unit (ICU), an invention of the 1960s and 1970s, vividly illustrates the problem. Patients there are supported by an extraordinary array of breathtaking technologies and pharmaceuticals (mechanical ventilation, dialysis, and vasoactive and thrombolytic drugs, to name a few), each accompanied by an armada of skilled professionals to manage their use. A critically ill patient might be seen by a half-dozen different physician-specialists and scores of nurses, respiratory therapists, pharmacists, social workers, clergy, and others, and receive hundreds of medications and tests. It should come as no surprise, then, that without a culture, procedures, and technology focused on flaw- less execution, errors would become commonplace. One study found that the average ICU patient experiences 1.7 errors per day, nearly one-third of which are potentially life-threatening.’

 

We need to understand the healthcare safety problem is not bad people:

image

Our hospitals are increasingly complex and humans err. These adverse events will continue to occur if we don’t act wisely.

Line mis-connections can be designed out. The FDA are developing standards for line connections (see here) – similar standards must be adopted worldwide.

Intelligent design throughout our hospitals will save tens of thousands of lives.  Where possible we need to introduce these most effective safety solutions, focusing on the systems in which front line staff work.
Hierarchy
Graphic by Joseph A. Cafazzo and Olivier St-Cyr

 

Front line staff are often aware of poor system and device design. Given the opportunity and support we can develop simpler, safer work environments, allowing greater focus on patient care. Other industries have adopted six sigma and lean efficiency with great benefit.

Equipment and processes should be assessed through simulated environments, yet still we need the ability to remove hazards even after they’ve reached the front line.

We need the system to be able to learn learn from its mistakes. In Australia this process will frequently involve the Therapeutic and Goods Administration.

The TGA need to be empowered to listen and act on the feedback of front line staff.

For a great introduction to intelligent design please read ‘The Design of Everyday Things’ by Donald Norman

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