Do People Or Processes Cause Healthcare Mistakes?

Healthcare is a critical industry where the consequences of even the slightest mistake can be fatal. As a result, there is always an abundance of blame to pass around when things go wrong.

However, when it comes to healthcare mistakes, is it always fair to blame the individuals involved, or should we consider broader systemic issues? In this blog post, we'll explore the question of whether people or processes cause healthcare mistakes.

Systems vs People

According to W. Edwards Deming, a renowned management expert, "94% of all failure is a result of the system… not people." This idea challenges the common perception that most healthcare mistakes result from the negligence or incompetence of individual healthcare professionals. While it's undeniable that human error plays a role, focusing solely on individuals ignores the systemic issues that contribute to errors in healthcare.

One problem is that many systemic errors in healthcare are deeply ingrained in the culture — "that's the way it's always been done." This error of thinking leads to a reluctance to change even when new approaches could improve patient outcomes. To address this, we need to treat healthcare systems the way we treat patients. That means assuming that seemingly unrelated problems are, in fact, related and applying Occam's Razor to identify the root cause of problems.

Small Problems, High Costs

Currently, healthcare system problems are often only partially treated, and these new "treatments" often create more problems elsewhere. The new problems aren't seen to be related to changes in other parts of the healthcare system, by either those causing the changes, or those dealing with the new problem. This contributes to the more than 20% waste in healthcare spending seen worldwide (OECD 2017).

One reason we often fail to take a holistic view of healthcare systems is that individual problems affect relatively few people, with only small consequences or expenses. However, the accumulation of many small problems leads to a significant financial and societal cost. By failing to address systemic issues, we pay more than we should for healthcare and jeopardize patients' well-being.

Contrast this with the oil and gas industry, or aviation, which has a different mindset due to the high stakes involved. A small mistake in these industries can lead to a disaster with many casualties, a highly visible environmental impact, and expensive cleanup and compensation. Because of this risk, oil, gas and aviation place a strong emphasis on preventing errors by looking at systemic issues, not just individual mistakes. Healthcare should learn from this approach and adopt a similar mindset.

How can we reduce system errors?

So what can be done at an enterprise level to reduce system errors? The complexity of healthcare delivery and enormous variation in size of facilities and mix of operations that they perform means that a 'one size fits all' approach is likely to fail.

Using information technology to support humans with repetitive processes helps to free healthcare workers from the drudgery that takes them away from patient contact, the main reason that most people get in to healthcare in the first place.

Unfortunately, many IT projects turn inefficient paper processes into inefficient electronic processes, resulting in more screen time over human-time.

Successful IT projects look for overlap and commonalities where IT can connect the dots and bridge the gaps. This is why a solution like SOx has been created to leverage this important concept and offer significant benefits in healthcare through:

• Streamlining of ordering process so that if an element of a procedure changes, other dependent elements automatically change as well, removing clerical errors.
• Connection of surgeons, hospitals, supplies and their patients to dramatically reduce the frustration of duplication and errors.
• Reallocation of healthcare workers' time to direct patient interaction, thus adding a personal touch to healthcare delivery.

Conclusion

While individual healthcare professionals may play a role in healthcare mistakes, it is clear that the vast majority of errors are systemic rather than personal. We need to shift our focus from blame to finding and addressing the root cause of problems. It's time to re-examine the healthcare system and take a more holistic approach to ensure that patients receive the best care possible. By doing so, we can reduce waste, improve outcomes, and most importantly, save lives.

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