Lucy Glenn, MD, spoke this morning on strategies for minimizing errors in diagnostic imaging. She began by discussing the concept of “zero defects”: “We as health care workers have to change our mindset,” she said. “What the typical organization wants is very few defects. We have to embrace what the patient wants, which is no defects. We have to get to a mindset where we think that perfection is possible and injuries are avoidable.”
According to Glenn, even 99.9% reliability is unacceptable: “At 99.9% we’d have two major airline crashes a week,” she pointed out. “That’s why zero defects has to be the goal.”
The first step is creating a culture of safety. “Culture eats strategy for lunch,” she said. “Unless you have hearts committed to this as well as minds, you’ll never be successful at changing anything.” The second step is creating a culture of continuous improvement, where errors are addressed and lessons learned.
Human beings have a 3% error rate. So how do we get to zero defects? “Mistakes are inevitable, but reversible,” Glenn said. “If a system picks up an error before it’s too far along and the mistake is addressed, you can reach zero defects.”
After a mistake has been detected and corrected, Glenn said, self-examination is necessary in order to redesign processes so that the mistake can never be made again. One example she offered is tying your PACS system to your dictation software so that it’s impossible to work on the wrong patient’s report. “You want to get from checking for defects to actually preventing errors,” she said.
Glenn offered a few steps toward zero defects:
--Embed safety in every step of every process
--Correct mistakes as soon as possible and as close as possible to their point of origin
--“Stop the line” for any safety issue
At Glenn’s facility, a patient safety alert system has been implemented. Every time a PSA is reported, it’s coded yellow, orange or red, according to severity; then the resources to correct the mistake are assigned based on the level of severity. A yellow PSA is handled on the departmental level; an orange PSA may require stopping some process before investigating, and a VP is involved; and a red PSA has the potential to cause actual harm to the patient, requires multi-department coordination to address and is investigated within 24 hours. “The closer you get to the error, the easier it is to determine the root cause,” Glenn said.
Most radiology PSAs at her facility are caused by communication issues or not following training. “What happens when you find the error and it’s obviously a human issue?” she said. “Health care used to be a blame culture. About mid-1990s, we changed over to a systems approach, acknowledging human fallibility. But there was still no accountability for those individuals who displayed unsafe behavior. Somewhere between the two is where we want to be.”
Good system design and good behavioral choices are the key to eliminating defects, according to Glenn. “Human error occurs,” she said. “When it’s an honest mistake, you don’t want to punish that person. But there’s also at-risk behavior.” For a human error, the proper response is to console; for at-risk behavior, the response should be to coach; and for reckless behavior, the response should be to punish.
Glenn reminded the audience that “behavioral drift” can happen to any of us, so it’s important to be vigilant. “Behavioral drift occurs,” she said. “The speed limit’s 55. How fast do you usually drive?”