Boston University professor Anita Tucker and I studied nurses carrying out the dozens of tasks that occupied them throughout long hospital shifts. Taking detailed notes, complete with time stamps, to document the work of these dedicated caregivers at nine hospitals, Anita observed that nurses confronted âprocess failuresâ surprisingly oftenâalmost one an hour. A process failure was anything that disrupted a nurseâs ability to complete a task, such as an unexpected supply shortage in bed linens or medications. The nurses were acutely aware of these frustrating daily hurdles. Their jobs were hard enough! On average nurses were working an extra (unpaid) forty-five minutes simply to tie up loose ends before leaving the hospital.
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After a retrospective, itâs a good idea to write down the learnings and share them widely. A team growing hardy from its own successes and missteps is great, but when they can also help others improve or avoid similar errors, thatâs even better. At the end of the day, a resilient organization isnât one that never makes mistakes but rather one whose mistakes make it stronger over time.
Resilient processes also try to create repeatable best practices. Most of the work needed to make something happen in todayâs world is staggeringly complex. Just imagine the number of steps it takes to get a plane to take offâthe cabin must be cleaned from the previous flight, the jet must be refueled, passengers must be checked in, luggage must be loaded, safety checks must be done, and so forth. Itâs near impossible to remember all the steps in your head, let alone try to improvise them in the moment.
Like many theoretically preventable failures, the basic failure at the Emergent BioSolutions plant was not an isolated incident but reflected a problematic safety culture, as suggested by the following reported events: Earlier vaccine lots had also been thrown out for contamination. Mold was a persistent problem in areas that were supposed to be kept immaculately clean. Supervision and training were scant for the many new hires needed to handle the mammoth vaccine production. Although vaccine manufacturing is known as a âfickleâ business and some error is inevitable, the reports suggested a pattern of lapses had led to the high-profile contamination of millions of doses. When inattention becomes a cultural feature in an organization, you have a breeding ground for producing basic and complex failures alike. Fatigue plays a role in slips due to inattention. The U.S. Centers for Disease Control and Prevention (CDC) reports that a third of adult Americans do not get enough sleep. Such alarming sleep deprivation not only leads to an array of health concerns, but also to accidents and injuries. To cite one example, investigators found that 40 percent of highway accidents identified human fatigue as a âprobable cause, a contributing factor, or a finding,â despite the fact that the National Transportation Safety Board (NTSB) has made 205 fatigue-specific recommendations since the early 1970s.
In contrast, for 7 percent of the process failures, nurses engaged in what we dubbed âsecond-order problem-solving.â This could mean simply informing a supervisor or someone in charge of linens about the shortage. Second-order problem-solving got the immediate task done and did something to prevent the problem from recurring.
We can easily understand why busy nurses rarely engaged in second-order problem-solving. But this left them vulnerable to continued frustration because the work-arounds didnât reduce the frequency of future process failures. The average time a nurse spent on work-arounds (a few minutes here, a few minutes there) added up to about half an hour per shiftâa substantial waste of skilled professionalsâ time. Like all quick fixes, the nursesâ work-arounds created an illusion of effectiveness. Confront a problem, implement a work-around, get on with your day. End of story.
âUse Systems Thinking to Change How We Think about Error âŚ
Rely on inquiry
So Morath faced a challenge: How to help people to see and accept their hospitalâs failures? Rather than doubling down on her logicâYou work in a complex error-prone system, donât you see? Things will go wrong!âshe instead invited clinicians to reflect on their experiences that week with their patients, then prompted, âWas everything as safe as you would have liked it to have been?â Her aspirational question opened the floodgates. Most people had been in what Morath called âa health-care situation where something did not go well,â and
once they reflected on the many problems they had noticed, they became eager to talk about what had happened and how they might improveâŚ
New language
Another element of the patient safety system was what Morath called Words to Work Byâa roster of suggested terms designed to help shift mindsets from blaming to learning. Morath substituted neutral-sounding words such as study for the more threatening word investigation, which put people on the defensiveâŚ
SynergyâŚ
As with the system at 3M that supported peopleâs intelligent failures in ways that encouraged product innovation, and the system at Toyota that made quality improvement second nature, Childrenâs Minnesota built a robust learning system that turned everyone into an active participant in patient safety. Morathâs approach reminds us that system design is more than simply coming into an organization and flipping a single switch. Itâs flipping multiple switches understanding how they work as a system.