Sometimes I read about problems in hospitals and I want to start yelling at people to tell them how obvious it is that a lean approach would help.
The ECRI Institute, which researches patient safety issues, has issued its second annual report on the top 10 technology hazards that every hospital should pay more attention to.
As reported in The Wall Street Journal Health Blog, the issues are:
1. Alarm hazards
2. Needle-sticks and injuries from sharps
3. Air embolisms from contrast media injectors
4. Retained devices and fragments left in patients
5. Surgical fires
By the way, the list is much longer than five items. Those are just the ones that appear to be most prevalent this year. (The top items change from year to year.)
The WSJ blog quotes Dan Ault, author of the report, as saying the intent is to point out problems so they can be solved.
However, what I find most significant is what Ault has to say about the causes of the problems.
While some problems involve a faulty device alone, he says, there’s usually some contribution from the operator. “No one reads the manual, or even has the manual after day one,” he says. Even if they are trained properly, he adds, “they get busy or move on to something else.”
Yes, but the way to solve these problems is to apply lean methods. First, ask why five times (or as many times as it takes to get a meaningful answer) to find out the true causes of the problems. I’m sure it is not just operator negligence, though lack of training might be an issue.
The solutions may involve better training, implementing standard work, mistake-proofing or a variety of other lean tools.
I am glad ECRI issues the report, but it needs follow-up. Someone should write a report suggesting solutions – or better yet, identify institutions that have the lowest problem rates and report on how they achieved that.