8/13/2019 Proactive Resolution of Near

1/2

Proactive Resolution of Near-Miss Problems

In addition to FMEA brainstorming, hospitals must react appropriately to near misses,turning each problem into an opportunity to drive process improvements that preventthat same error from happening again.

One foreseeable hospital process defect is administering an incorrect intravenous dripto a patient. Potential risks include giving the wrong dose or the wrong medication. Onestudy estimated an error was made in 49% of intravenous preparations andadministrations. [43]While there are numerous checks and rechecks of intravenous bagsduring the intravenous production process in the pharmacy, errors still get through tothe point at which a nurse is poised potentially to administer the wrong drug. The factthat all errors are not caught in the pharmacy is evidence of how 100% inspection is not100% effective, even with multiple successive inspections.

Think about a case in which a nurse properly inspects the medication and finds an errorat that last stage of the value stream of the intravenous bag through the hospital. In a

perfectly error-proofed process, this should never happen. The nurse's reaction

andthe reaction of the organizationto such a near miss is crucial. A non-Leanorganization might consider the nurse catching the error by the pharmacy as proof thatthe system worked. People might ask, "What is the problem? The patientwas notharmed." Catching the error before the patientwas harmed is certainly a positive event,but it should be considered the sign of a weak process that allowed the error to get asfar as it did. The next time, the nurse might not catch the error in time.

A common workaround would be for the nurse to correct the immediate problem, forexample, by going and getting the right dose. The real problem is not solved, however,as the error is likely to be repeated if the root cause of the underlying error is not solved.The nurse might say "We were lucky. Let's hope that doesn't happen again." Theremight be a temptation not to report the problem or to cover up the near miss.Employees, including the nurse, might not have the time to follow up properly orconduct root cause problem-solving analysis because of overwork and the need tomove on to caring for other patients. The error will certainly happen again, at somepoint, because of the same systemic cause.

In the McClinton case, let us assume that the syringe was being filled with the wrongsolution, but another person in the room saw the error and called it out. This would-be"near miss" would have been as much of an opportunity to improve the process and toprevent any harm to patients.

In a Lean culture, we need a number of conditions to ensure that the root cause issolved, including

An environment in which employees are encouraged to stop and solve problemswhen they are found (or as soon as possible)

Available time for root cause problem solving (freed up through earlier wastereduction)

A blame-free environment in which employees are not punished for raisingproblems to the surface for root cause problem solving

http://library.books24x7.com/assetviewer.aspx?bookid=46710&chunkid=568245760&rowid=545&noteMenuToggle=0&hitSectionMenuToggle=0&leftMenuState=1#ftn.ch07fnt43http://library.books24x7.com/assetviewer.aspx?bookid=46710&chunkid=568245760&rowid=545&noteMenuToggle=0&hitSectionMenuToggle=0&leftMenuState=1#ftn.ch07fnt43http://library.books24x7.com/assetviewer.aspx?bookid=46710&chunkid=568245760&rowid=545&noteMenuToggle=0&hitSectionMenuToggle=0&leftMenuState=1#ftn.ch07fnt43http://library.books24x7.com/assetviewer.aspx?bookid=46710&chunkid=568245760&rowid=545&noteMenuToggle=0&hitSectionMenuToggle=0&leftMenuState=1#ftn.ch07fnt43

8/13/2019 Proactive Resolution of Near

2/2

Managers who take the time to help resolve issues with or for employees as theyare raised

Cross-functional cooperation to work together on problems that are generatedupstream but create waste for a downstream function or department

Figure 7.3: The Alcoa safetypyramid. (Adapted from Woletz and Alcoa.)

[43]Taxis, K., and N. Barber, "Ethnographic Study of Incidence and Severity of

Intravenous Drug Errors," British Medical Journal,2003, 326: 684.

http://library.books24x7.com/assetviewer.aspx?bookid=46710&chunkid=568245760&rowid=545&noteMenuToggle=0&hitSectionMenuToggle=0&leftMenuState=1#ch07fnt43http://library.books24x7.com/assetviewer.aspx?bookid=46710&chunkid=568245760&rowid=545&noteMenuToggle=0&hitSectionMenuToggle=0&leftMenuState=1#ch07fnt43http://library.books24x7.com/assetviewer.aspx?bookid=46710&chunkid=568245760&rowid=545&noteMenuToggle=0&hitSectionMenuToggle=0&leftMenuState=1#ch07fnt43http://popimage%28%27img_25%27%2C%27http//images.books24x7.com/bookimages/id_46710/fig7-3_0.jpg','537','481')http://library.books24x7.com/assetviewer.aspx?bookid=46710&chunkid=568245760&rowid=545&noteMenuToggle=0&hitSectionMenuToggle=0&leftMenuState=1#ch07fnt43