The cases of Ebola in the U.S. have brought a sharp focus onto a recurrent and enduring problem in our country – one that has plagued all industries, but now brings a sharp focus onto health care.
The problem is error reduction.
The initial blame placed on the second Ebola infected nurse, who flew a commercial flight while febrile and symptomatic, was quickly countered because she sought advice from the Centers of Disease Control and Prevention (CDC). The CDC then countered that she failed to supply key information that would have changed their response, when asked about a low grade fever. This is a classic illustration of the blame game.
The goal of a high quality / low error process is to remove blame and finger-pointing, and create the process to prevent errors while minimizing the human error that will inevitably occur. Manufacturers learned that to avoid workers getting their hand pinched in a device they actuate; they needed to have the device operated by two controls that could only be activated with two hands that were far away from the pinch point.
No longer did they need to instruct workers to “keep your hand away when you push the button,” and suffer the inevitable when rules were ignored. To avoid error, ignorance is removed by educating about the pinch points and what you needed to do. They avoided stupidity by knowing what to do and not doing it, by making it difficult, if not impossible to hurt yourself.
We have to continue to create processes that avoid errors, through open and transparent education. We also need to create processes that minimize stupidity, which has been apparently demonstrated twice when individuals withheld information that would almost certainly have altered the answers they got.
Patients withhold information for many reasons. Some of the reasons are fear (not wanting to know, or being afraid of the answer), testing (seeing if you ask, and if you don’t it must not be important), ignorance (not realizing the information is critical to the decision), and finally stupidity (deliberately withholding critical information you know to be important for any reason.)
As we work through all the issues surrounding Ebola, and every other disease or threat to our health, using any quality improvement methodology involves creation of processes that minimize and correct ignorance and minimize the occurrence and effect of the inevitable mistakes that occur.
We have to work our way carefully though this issue, like we should work our way through any. We need to pay attention to the details, considering every unexpected possible consequence and account for them. You can’t fix stupid, but you can minimize how often it hurts you.
