On Lean Daily Management rounds last week one of our units reported a missing dose of insulin from the day before. A nurse went to give a patient insulin at 6:00 a.m. However, the insulin, which had been ordered more than five hours earlier, was not there. The nurse, concerned that the patient was about to eat breakfast and the risk of hyperglycemia quickly called the pharmacy who raced to deliver the medication. Further problems were averted and the staff breathed a proverbial sigh of relief.
But what happened next? The staff, both on the floor and in the Pharmacy went back to their work. When I asked the person presenting the board what did they learn as to the reason why the insulin was not there the answer was that they did not know because no one as yet had investigated it. Now before you as the reader get upset with me and say “there he goes again, this guy doesn't know how hard the nurses and pharmacists are working…when did he expect them to study this?” - I accept your criticism. We leaders must create the capability to study these errors in real time if we are serious about fixing the “latent” errors that lead to near misses and then sometimes to full-blown catastrophes. We must create both the zeal to learn why the defect occurred and the resource to study it and fix it as quickly as possible. Eventually some patient may get hurt because we didn't learn why this patient dodged a bullet.
We are making excellent progress toward our vision in our healthcare system. But the question remains what can we do to move faster? One answer is to be preoccupied that if we don’t learn why a defect happened someone could get hurt and be less likely to work around a defect in our system and go back to work.
I welcome your comments.