7.15.2009

A Nursing Home Death Should Raise Process Issues

When a problem exists – and is recognized as a problem – the lean approach is to ask “why” as many times as necessary to identify the cause of the problem and develop a solution,

A recent tragic incident in California cries out for that approach.

The California Department of Public Health levied a $100,000 fine (the highest possible under state law) on Aviara Healthcare Center, a nursing home located in Encinitas (San Diego County).

A news release from the department describes in clear, simple terms the reason for the fine.


The facility created a hazard by improperly storing a large mechanical patient lift in a hallway. A patient grabbed the lift during a fall, tipping it over. The resulting injuries led to the patient’s death.


The first question is why the lift was being stored in the hallway. Is there a specific place where it should have been stored? If not, why not? Is there no storage space for it anywhere? Are there no procedures in place for checking lifts in and out of storage, or for returning them to storage once they have been used?

But those aren’t the only questions. Imagine that the lift had not been in the hallway. Was there anything that could have been done to prevent the patient from falling? Are there railings in the hallway, for example? Falls are a common occurrence among elderly, infirm patients, and not all falls can be prevented. But the question is worth asking.

Unfortunately, I suspect that these questions may not get asked. Too often in this kind of situation, those in charge focus only on the obvious – i.e., a patient died and we got fined for leaving a lift in a hallway, so let’s not leave lifts in hallways. They may not know how to think in lean terms to identify broader issues in their processes.

That is not always true. Sometimes a serious incident such as this one can serve as a wake-up call. I hope it does in this case.

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