Originally Published MDDI August 2003

NEWSTRENDS

Gregg Nighswonger

The potential for adverse events in hospitals, whether caused by device malfunction or human error, has been the focus of increased public and industry concern. 

The costs associated with such events—in the form of lost income, disability payments, and healthcare expenses—are estimated at as much as $29 billion annually. Medical errors often have consequences that are more severe than those in other industries, prompting the healthcare industry to consider a range of possible remedies. Recently, a professor at Berry College (Rome, GA) proposed that one way to reduce or eliminate adverse events is to intentionally design targeted failures into medical systems.

John Grout, David C. Garrett Jr. associate professor of business administration at Berry College, admits that purposefully designing failure into healthcare processes might be the surprising answer to preventing medical errors. Nevertheless, he proposes that taking such an approach could make healthcare processes more resistant to the tendencies of human beings to make mistakes. Specifically, he suggests that medical processes be designed to fail benignly before patient injuries occur—rather than building in additional, often costly, checks and redundancies.

According to Grout, “Medical mistakes, which kill tens of thousands of Americans each year, too often are caused by healthcare workers simply being human. They make mistakes that cause failures in the processes used for patient care. Research has shown that no amount of punishment, berating, finger-pointing, or guilt will eliminate human error. Regardless of good intentions and extensive training, people will make mistakes—and some of them will be deadly.”

Grout believes that it is more sensible “to design medical systems that make human error irrelevant to outcomes than to create more checks and redundancies for already over-burdened nursing personnel and other healthcare providers.” Staff workloads are a principal consideration. He adds, “Increasing nurses' work load or the need for more nurses isn't practical or affordable. Designing processes that fail before a patient is injured may well be both.”

Grout uses the example of scalding a patient with too-hot bath water as a harmful process failure that can be caused by human error and prevented by a planned, benign process failure. “Even if there are checks and redundancies built into the system, it is possible for caregivers to make a variety of errors that lead to scalding,” he explained. “It can be as simple as misreading a temperature gauge.” 

While no water coming from the tap at bath time also is a process failure, he continued, it is inconvenient but not dangerous. In medical terminology, it is benign. Grout suggests that this type of benign failure can be designed into processes, thus preventing patient injury. “A scald valve could be installed that restricts flow from the tap if the water temperature exceeds a certain level,” he stated, “causing the system to fail before the patient is injured even if the caregiver makes a mistake.”

Grout explains that this approach is based upon a conclusion reached long ago in such fields as psychology, engineering, and quality management: If you want to reduce errors, you have to stop processes from proceeding when they go awry. 

Grout's approach is based on the use of graphic fault trees to map processes and identify their potential areas of both dangerous and benign breakdown. “A careful analysis of the fault trees enables an analyst to anticipate how the process will behave after a change is made,” Grout explains. “Process failures that cause harm can be converted into the causes of benign failures.”

Grout first presented his approach for eliminating medical errors at the Partnership for Patient Safety's international symposium held October 2002 in Washington, DC. More recently, he described his proposal in the July 2003 issue of the Joint Commission Journal of Quality and Safety, published by the Joint Commission on Accreditation of Health Care Organizations.

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