Patient Safety Tip of the Week
August 7, 2007
Role of
Maintenance in Incidents
Many of the most
famous disasters in industry history have followed equipment or facilities
maintenance activities, whether planned, routine, or problem-oriented.
Well-known examples include Chernobyl, Three-Mile Island, the Bhopal chemical
release, and a variety of airline incidents and oil/gas explosions. It is
unknown how often maintenance activities contribute to medical incidents but,
given the similarity of systems in medicine to those in other high-risk
industries, it is likely that there are many cases in which maintenance errors
contribute to adverse patient outcomes.
James Reason and
Alan Hobbs in their 2003 book “Managing Maintenance Error. A Practical Guide”
do an outstanding job of describing the types of errors encountered in
maintenance activities, where and under what circumstances the various types of
error are likely to occur, and steps to minimize the risks.
Omissions are
the single largest category of maintenance errors. Omissions are especially
likely to occur after interruptions or distractions. We frequently “lose our
place” when performing a series of actions and then either unnecessarily repeat
a step or omit a step or steps altogether. Omissions are also especially prone
to occur near the end of a sequence of steps. This may be part of the “premature
exit” phenomenon where one is already thinking about the next activity and
leaves out a step in the current activity.
The book has an
excellent discussion of error-provoking factors that come into play at both the
individual level and the team level, including how to recognize them and how to
deal with them. It has a particularly good discussion of violations (which are
intentional deviations from standards) and the reasons for them and a useful
approach that one company took to reduce them.
Don Norman’s
work on design of systems is cited and the importance of involving end-users in
the equipment purchasing phase is emphasized. This, of course, helps the
organization help identify some of the safety issues that will arise with such
new equipment. Hospitals and healthcare facilities need to adhere to that
principle more often. They especially stress the end-user role in understanding
equipment having multiple modes (that is, controls do different things
depending upon what “mode” the machine is in), another issue frequently lacking
in healthcare settings. “Automation surprises” (such as this mode confusion
issue) are frequently mentioned as root causes in the aviation safety
literature but probably occur as often in healthcare.
A section on omission-provoking
features more than justifies buying this book. It includes an annotated “task
step checklist” that will help your organization identify omission-prone tasks
and better manage them. It also includes a discussion of the characteristics of
a good reminder (many of these characteristics are incorporated into the ISMP
guideline on good lablels for high-alert drugs that we discussed in last week’s
Tip of the Week).
In healthcare,
we talk about the importance of reporting near-misses and other issues
proactively to help prevent errors and adverse outcomes. We usually stress the
importance of developing anonymous reporting systems or error-reporting
hotlines. This book describes and interesting method probably not widely used
in healthcare. It describes the MESH (Managing Engineering Safety Health)
system. MESH is a sampling tool given to randomly selected frontline workers to
rate weekly (or monthly) a number of factors affecting the local workplace
environment of the more general organizational environment. The resulting
cumulated local factor profile allows identification of those factors occurring
with sufficient frequency to help direct limited resources to areas in which
ROI is likely to be high and help prioritize safety and quality goals. This
book also has a good description of “just culture” (encouraging that the vast
majority of errors reported are not punished but continuing to take action in
the rare cases where reckless behavior occurred) and a very good description of
the attributes of a successful reporting system. And it ends with a great
discussion about the nature of “safety culture” and the “resilient”
organization..
The book also
has the overview of human factors, description of various human error types,
and models of organizational accidents that you’d expect of any James Reason
book. It gives real-life examples of incidents from several industries. Many of
our “big three” issues (failed handoffs or other communication failures,
failure to buck the authority gradient, and failure to heed alarms) are
contributing factors in those examples. But they really emphasize some other
aspects that we think about less often in healthcare but clearly need to
integrate into our thinking.
Quite frankly,
most of the lessons in this book apply not just to maintenance activities but
to any process or procedure involving multiple steps. The caveat that steps
near the end of a maintenance procedure are most likely to be omitted
(“premature exit”) or that violations tend to occur frequently when under time
pressure to complete a task certainly applies to many things we do in
healthcare, not just equipment maintenance. The same issues could just as
easily apply to a surgical case in the operating room or the delivery of
chemotherapy on a medical unit.
References:
Reason J, Hobbs A. Managing Maintenance Error. Aldershot, England: Ashgate Publishing Limited, 2003
Norman DA, The Design of Everyday Things. New York: Doubleday; 1989
(in paperback by Basic Books 2002)
Norman DA, The Design of Future Things. New York: Basic Books; 2007
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