Saturday, October 4, 2014

To Err Is Human…. And You Still Can’t Fix Stupid

Way back in 1999 the Institute of Medicine (IOM) issued its landmark report on medical errors, To Err Is Human: Building a Safer Health System. The report's finding that as many as 98,000 people die each year due to medical errors ignited professional and public dialogue. Some changes were made in response to this report. Most notably when you have surgery everyone, I mean EVERYONE, ask you who you are and what body part is having surgery. “X” marks the spot and for the most part they cut and dig in the right places these days.

Last week a man from Ebola-ravaged Liberia was taken to the emergency room at Texas Presbyterian Hospital in Dallas. This man had all of the symptoms associated with Ebola and had just arrived from West Africa. Whoever admitted this gentleman had this information but somehow failed to communicate it to the medical team. Even still, one would think that reasonably intelligent doctors and nurses would recognize that this black man might not be from around here and perhaps they should double check his recent travel history given the symptoms. He did not have an African sounding name, so perhaps that led the medical team to think he was a local. And he was probably too ill to speak for himself. But somewhere along this chain of events, at least one person knew exactly where he had been and several should have suspected. Nonetheless, he was given some totally useless antibiotics and sent away. Several days later he was brought back, even sicker, after having exposed dozens of people to the Ebola virus. We are still waiting to find out if any of those individuals are actually infected.

The healthcare industry is not unlike other industries. The stakes are higher and more precautions are taken. And we pay a premium for the level of quality and safety we do receive from our healthcare system. But, they still make mistakes, do the wrong thing or fail to do the right thing. Just like other industries. We talk a lot about quality and in many ways products are better than they used to be. Design, engineering and manufacturing processes are, for the most part, very good. When there are bugs or glitches they get fixed. But when quality depends on a significant level of human involvement at the point of delivery…watch out.

If you pay attention, you’ll find that you seldom get a “perfect order” if the content of direct human input is very high. Most of the time it’s good enough and we don’t complain. So companies still feel OK about their service. At least until their customers quit buying. Honestly, I am surprised when anyone actually “gets it right”. I don’t know if service is getting worse, but it’s definitely not getting better. And furthermore, no one really notices or cares very much. In fact, it has sort of become an excuse for all of us doing a half-assed job at whatever it is we do.

We talk a lot about better, faster, cheaper…but the real order of priority is cheaper, faster and better. And better really means “perceived better” than the competition. So we consumers make trade-offs between price (cheaper), convenience (faster) and quality (better); and businesses respond accordingly. A lot of the time, the order you pick up at the drive-thru window is wrong, so you learn to check it. You know that the “sack boy” is clueless and/or doesn’t care so you watch how he bags your groceries. You buy warranties and keep your expectations low. If your computer runs slow it’s probably your own fault and if you can’t sleep at night it’s because that “number mattress” didn’t come in half-sizes or you should have bought the better (more expensive) pillows. And once in awhile, a person infected with a deadly virus walks out of a hospital emergency room.

No comments: