is the fourth post in an occasional series by Kyle E. Johnson, PMP,
Administrative Fellow, St. Charles Health System, about how the IHI Open School
courses are helping to change culture in the hospital. Click here to see his first three posts.
After the announcement that the IHI Basic Certificate would
be the foundation for quality improvement training and education at St.
Charles, one of my colleagues experienced a medical error. She had just picked
up some asthma medication for her 2-year old daughter at our retail pharmacy
and was getting ready to give it to her when she noticed that the last name on
the label didn’t match hers. The medication and the first name on the label
were the same, but the last name was different and the dosage was for an adult.
There was an additional medication in the bag that was for an adult.
Thankfully, my colleague caught the error before the medication was
administered and no harm was done, but I had to ask myself, “Could this happen
When I first heard about this experience, I asked my
colleague what she had done afterwards. She stated that she chose not to pursue
the issue further because she didn’t want to get the pharmacist in trouble for
what was obviously an accident. After some discussion, we agreed that the error
was probably not due to negligence, but was more likely the result of a current
process or system. Armed with only my colleague’s blessing, my unbridled
enthusiasm, and the improvement tools I learned through the Open School, I set
out to learn what I could and to help make sure that this type of error
wouldn’t happen again.
The true power of the Open School derives not just from the
problem-solving and data analytics tools it teaches on the IHI website,
although these are critical to understand. The true power derives from learning
to look at the world from a perspective of improvement. The Open School teaches
you that continuous improvement is really continuous learning and that, in
order to improve health care, you must embrace failure as a part of the
learning process. For many people, this is a fundamentally different way of
seeing the world.
The human brain likes a story and every good story has an
antagonist. We want to blame the bad doctor or the lazy nurse. We naturally
expect to see a regretful pharmacist or an ashamed administrator. But in this
case and most others, medical errors are not the fault of a single individual.
Instead, they are products of deficient systems and processes, and must be addressed
as such. With my improvement goggles on, I went to see our retail pharmacy
manager to discuss what had happened. What I didn’t realize was just how much
the Open School had caused me to view the world differently. Below is an
abbreviated version of our conversation:
Me: What do you think was the cause of this
Manager: We know the cause. The person working at the
counter didn’t verify birth date before handing over the medication. The bag
had the correct name, but the birth date should’ve been verified first.
Me: Are your processes standardized and written down
so that everyone knows what the correct process is?
Manager: Some of them. I don’t think this one is,
Me: So how do you know that this was the only cause
and that there weren’t any other contributing factors?
Manager: We already solved the problem. We posted a
sign at the counter reminding patients to verify their birth date, just in case
the person working at the counter forgets to ask.
Me: Sounds good. Has the change been effective at
Me: How do you know?
Manager: … I guess we don’t.
This conversation ended amicably, but I made a strong
recommendation to the manager that he enroll in the Open School. A few weeks
later, I received an excited phone message from this manager stating that he
had not only enrolled, but had also worked through all the modules and obtained
his Basic Certificate. He was excited about improvement and couldn’t wait to
get started on conducting his own small tests of change. The improvement
goggles had been put on!
Although the human psyche naturally wants to tell a story
and find an antagonist when things go wrong, system problems require
system-type tools to solve them. The IHI Open School pairs data and process improvement
tools with real-life context and stories. It is helping our organization view
failure differently and to see the world from a perspective of improvement. We
are decreasingly convinced by the familiar (but naïve) story line that pins
medical errors on a single antagonist. And we are increasingly cognizant of the
reality that medical errors are a story involving and affecting all of us. Our
new stories are helping drive organizational change and lend context to the
science of improvement. In this way, our perspective has started to change.