Archives for May 2016

One of the better ways to reduce errors is to admit what went wrong and then how to solve those problems.  538 and Nate Silver got the Republican race fundamentally wrong as they were applying a modified “The Party Decides” framework as a core assumption to their analysis. Nate Silver has a good tweet on how he is changing his thinking now that Donald Trump is the Republican nominee:

 

Updated post-Trump priors:
1. Voters are more tribal than I thought.
2. GOP is weaker than I thought.
3. Media is worse than I thought.

— Nate Silver (@NateSilver538) May 1, 2016

This applies to hospitals and medical decision making errors.

Brigham and Women’s Hospital in Boston has an interesting approach about errors that are made at the hospital. They treat their errors as learning and process improvement opportunities. More importantly, they publish their errors.  Here is one sample:

 

What Happened
Nurse A was caring for a patient, Susan, and administered a dose of cough suppressant, which could be taken on an as needed basis every 8 hours, at 7:00 AM. Susan’s next dose, if needed, could therefore be given at 3:00 PM. That afternoon, a second nurse (Nurse B) was assigned to care for the patient while Nurse A was off the unit. Nurse B administered the next dose of medication because Susan was coughing. When Nurse A, resumed care of Susan, she gave her what she believed was Susan’s second dose of cough suppressant at 2:30 PM. Nurse A administered the medication at 2:30 p.m. because Susan was scheduled to leave the unit for testing and would not be back by 3:00 PM when the dose was originally scheduled. The nurse received a message in the electronic health record that the dose was being given early, “Based on the ordered frequency, this medication is possibly being administered too close to another administration.  Please review previous administrations to verify appropriateness.”  The message wasn’t surprising since she was purposefully giving her the second dose 30 minutes early. What she didn’t know is that Susan had already received the second dose from Nurse B. Fortunately, Susan was not harmed by this additional dose. 

What We Are Doing
When Nurse A filed the safety report about this event, she included an idea for avoiding similar events in the future. She suggested that the warning box in the electronic health record that highlights the early medication time, also include the time the last dose was given.  In this case, the warning would have alerted her to the time Nurse B administered the medication and prevented the duplicate dose.

Based on this error, safety report and improvement suggestion, IS (Information Services) is adding a best practice alert (BPA) displaying the last administration time for all PRN (as needed) medications.

We learn by our mistakes. We only learn when we figure out why a mistake was made and we can then re-adjust either our mental model or our practical routines to incorporate that new and valuable information.

Reducing errorsPost + Comments (27)