We ALL make Mistakes

 

Regardless of age, gender, culture or identity, all people at some point will mess up... we ALL make mistakes.  Rarely are they a conscious act for venal reasons.  They almost always come from common conscious distractions, unfortunately usually at the exact wrong time.  Most commonly they occur usually at home, but sometimes they happen at work, and in the exact wrong situation. 

Most mistakes happen where people spend most of their time, which is at home, or for those of a middle age, while at work.  Most are the consequences of inattention and distraction factors, such as in moody moments, or while rushing, or under interpersonal complications, or other external distractions, or moments of stress.  Many are a result of a compulsive need to multitask.

You get my point…  stuff happens, especially when we set ourselves up for risk and failure

People who look at this topic in a somewhat sciencey sort of way say that most of the time we are oblivious to our goofs, although sometimes, at a certain level of consciousness, we trigger a cerebral recognition response that will alert us that we messed up.  Apparently there is a subset that may be more likely to que into this response.  Some studies suggest that women may be more likely to atune to the trigger and more likely to seek confirmation

Many errors have some  things in common.  Most goofs are irrelevant or at worst inconvenient. Sometimes, albeit rare upon rare, they end up with tragic consequences with serious injury or worse.  ( consider daydreaming while driving!!).

It is difficult to find objective information on the frequency of work related errors because the situation to count them does not come up.  The closest we can get to objective monitoring is in those fields where people are required to participate in  objective Proficiency Testing.  We do this in most types of laboratories, as well in industries such as textiles, and ship building, and working with concrete and steel, and coloration, and electrial conduction.  (Consider what happens when a bridge is built with faulty concrete and the bridge falls down!!) In medical laboratories we can see that hands-on laboratory errors occur in most disciplines at a rate of about 1 percent of testing, which sounds pretty good, until you consider that in the United States there are about 14 billion tests done per year!  (United Kingdom- around 1 billion and Canada about 100 million). That accumulates to a lot of medical laboratory errors!!!  The good news is that near 100% of laboratories have to participate in proficiency testing, so you can get a fairly accurate count of errors. 

In other health disciplines, with so called "ocult observation" which means that a person is sitting at a desk and working, but what they are really doing is observing who is washing their hands.  As it rurns out hand washing at its best is usually at 50 percent.

Some self-reporting systems also exist where people who recognize and report a self error can be useful indicators, but only when the people involved actually recognize and report their error.  Clearly the workers need to have a high level of confidence that nothing bad will happen by choosing to report by entering their information. This tends to make the self reporting systems a lot less reliable.

But here’s the bigger (biggest?) problem… Most errors reported as laboratory errors (somewhere near 70% plus) occur long before the laboratory ever touched the sample.  These are called “pre-examination errors which means the error occured  before the sample got to the laboratory.  Sometimes the sample came from the wrong patient, or was collected incorrectly or was put into the wrong container, or were put in the wrong storage place, or was mislabled or transport incorrectly, plus, plus, plus (Lin Y, Spies NC, Zohner K, et al. (2025) "Pre-analytical phase errors constitute the vast majority of errors in clinical laboratory testing."  The point is the sample may go through a proper testing process which may still be wrong.

It is difficult to envision  a  way of detecting or preventing  these problems (errors) before a wrong result is delivered.  Perhaps in the going forward future, samples will be collected by informed AI driven robots that will reduce error collection and transport much closer to zero.  But this is not going to happen tomorrow.

That’s not to say there have not been some improvements in error prevention in healthcare.  Over the years the frequency of in-institution medication errors has dropped since first being reported in 1999 by introduction of computerized physician order entry and Barcode Medication Administration both of which remove people from the loop.   One the other side the number of falls related injuries in elder long-term care has decreased by the introduction of STEADI (Stopping Elderly Accidents, Deaths & Injuries), programs which has added more people into the loop.

If I am trying to make a point (and I am!) let me say that in an area that I know something about we have many, many, many signs of error. Healthcare is replete with error, most of it unconscious and unrecognized… hands that don’t get washed, samples that are collected incorrectly, testing that is not done correctly.  Something has to be done to finally start turning these around.   

If we look at reporting on these sorts of errors, there is little evidence that reporting on any these sorts of errors results in negative repercussions.  

So will healthcare organizations ever successfully address the constant but unmeasurable  internal errors in a meaningful way?  Certainly not today or tomorrow, but today I am more optimistic than I was several years ago.  

As long as we have humans being asked to complex procedures,  the odds of error free healthcare is probably unlikely.

 But with human ingenuity and better  collection and monitoring systems, we might be more likely  to get closer to error free healthcare, at least until we reach a crisis of insufficient working robot batteries. 

NEAR MISSES!!!

 

ISO 7101:2023 requires actions with respect to near misses, without providing a specific definition.  One can find a variety of workable definitions, most of which are similar to the World Health Organization (WHO) that states: “an error that has the potential to cause an adverse event (patient harm) but fails to do so because of chance or because it is intercepted”.   The frequency of near misses is usually indeterminate because if you were unaware of it its existence and similarly unaware of any impact, then it becomes essentially invisible… until it is too late. 

But let me tell you about  near misses that I see, not in healthcare, but closely related. The reason that I think this is relevant is because it is one of those instances where one can actually see, monitor and count near-miss  instances.

I live in a large city with many tourists.  To accommodate, the city provides  “rent-a-bike” stations all over the city.  A station is a rack of bicycles locked in stalls that can be opened with a credit card swipe.  The person picks their bicycle, swaps their card and then backs bike out of its stand and rides away.  It takes maybe 2 minutes. 

There is one across from where I live, so I get ample chance to sit and watch on any given day 2-10 events.

Unfortunately this stand is on the side of a high traffic road  and every day I seem many bicycles being pulled out just as a car goes by with the potential accident being dodged by milliseconds or millimetres.  Not all the renters are oblivious, some, maybe many, look around before pulling out the bike, but on any given day, it does not take a long time before I see a near collision in the making.   

To date I have probably seen well over 50 (maybe 100) near misses,  fortunately no hits…  yet.  Sometimes I have a chance to chat with the cyclist before the ride away.  One or two might respond with some surprise, but the rest are oblivious and are happy to just ride away.

What disturbs me is that what I am seeing is not something like a minor inconvenience.  These are events that when things do go wrong, someone is going to be hurt…. probably very badly.  Blood will spill, bones will break, people will die.

So that’s my observed experience about near misses through a planned, over time, direct but not published or peer reviewed observation.   

People commonly have one thing on their mind and are, in all likelihood, unaware (maybe oblivious)  of the risk around them.  They do this regularly and in all sorts of situations.  People seem to be unaware of the risk of a bad things happening … until it is too late.

I think that’s the point about  a lot, maybe all, near misses,  Dekker talks about drifting into failure or an underappreciation of the situation.  Things happen, and for the most part there are no consequences, indeed no appreciation of the bullet being dodged. 

So why am I raising this?  A variety of authors, including the International Organization for Standardization in their new standard ISO7101:2023  (Healthcare organization management — Management systems for quality in healthcare organizations — Requirements  writes that:  

the organization shall have a documented system to identify risks …. Controls shall define processes to capture and analyse  near misses, etc. and assess the risks and opportunities by identifying and analysing each risk.  

Tough to do when (if I am right) near misses happen around us all the time mostly when we are oblivious. 

 Bon mots.

 

PS:  Let me be clear, the main perpetrator to these potential crises is not the folks getting ready for some cycling fun; it is the jack-asses that put the stand in a dangerous place. 

What do you think?

 

The Fourth year of Awarding the Noble Prize at UBC PathDay 2026 celebrations

Yesterday was the annual even for the University of British Columbia’s Department of Pathology and Laboratory Medicine  day to celebrate students staff and faculty.  It is a day of projects,  presentations and recognition of jobs well done by student, staff and faculty, and an opportunity of us old guys to come back and celebrate with the collective, and a time to give back.

In my case it is the day that we recognize student achievements for projects and presentations that highlight activities and insights in Quality and Improvement.  It’s our (my family’s)  way to support the students who see what others can see but go that extra step to ensure that their work is more meaningful because they focus on eliminating  error and risk, and improving patient care. 

One example:

When people are admitted to hospital because of probable infection it is common place take cultures but also  get patients  started on broad spectrum antibiotics that provide best chance of success but increase the risk of developing complications including resistance.   When the cultures are completed and they have identified both the infecting bacteria  and the most effective antibiotic,  the drugs get changed adjusted quickly, unless the results come out on the weekend.  If the results are reported on a Monday to Friday, the drug change happens on the same day.  But if they arrive on Saturday or Sunday, there is a delay and the change often on  Monday.  One student saw this, and put in the time to develop and organize an observational study, and then asked the important question  “why?”  (Bacteria Don’t Take Weekends Off).  

Highlighting the questionable practice is the first step to change, improvement and reduction of risk!

This year we handed out seven awards to well deserving students that demonstrated a particular level of interest and excellence in projects focused on Laboratory Quality and Improvement.  Congratulations to all.

Making Healthcare Better 

It's CHANGE TIME for HEALTHCARE

I'M BACK!!!

It has been a while since I have been active in MMLQR.  I retired from my position as a Professor in Pathology and Laboratory Medicine with my major focus on Quality Managment and External Quality Assessment.   I was able to find a brilliant scholar with stong Quality Interests, and decided the best way to address change was to WALK AWAY.

My university, was generous and honoured me by granting  my Emeritus Professorship.   While I have not been actively active in the university I have continued in my interests in the arena of Quality, both inside and outside the medical laboratory, and have been active with the American Society for Quality (ASQ).  

I have been away but (I hope) I have kept my brain and interests intact.  

I have returned to MMLQR  because I would like to think I will be able to provide some interesting and perhaps provocative thoughts.

As a starter, I am looking at a BRAND NEW INTERNATIONAL standard based on a foundational  document now nearly 30 years old.

Just Culture

For those of you involved in the Quality arena, you know this phrase.  It does not mean "Just" in the sense of "merely culture".  "Just Culture" was introduced into Quality discussion around 1997 by James Reason (see Managing the Risks of Organizational Accidents 1997) when he was talking about organizations that have a work environment in which people may create problems, but work in an environment of trust in which people are encouraged, and rewarded(?) for drawing attention to what has happened, knowing that at some level there can be and will be a line between acceptable and unaccpetabl behaviour.  Just Culture was intended to provide a safe place to ensure that "messing up" was not always going to end up with someone being punished or fired.   Sydney Dekker embraced the concept in 2007 (see Just Culture: Balancing Safety and Accountability) and again new books on the theme near every 5 years (the last and latest was in 2024)   

All are good reads.  If you can find them, they are nice written, and conversational in tone. 

The books put forward the notion that if the environment is safe and "just", workers will be forthcoming of all their errors, goofs, and near misses, a notion with which I have some struggles.  Without going into detail at this time,  my experience and observation is that many workers are oblivious of their errors, and for those that do notice them,  often the errors are self  interpreted as minor or likely inconsequential. 

I will tell you a story.  A few years back I was given an opportunity to look at files that were gathered by my province (British Columbia) on errors identified in medical laboratories.  The concept was that if people identified they have caused a problem, they would self report into the laboratory computer and the information was then stratified by type of error, interpreted severity of error etc.  I was able to create a number of manuscripts from the data (look for Noble et all, in Diagnosis (Berl) 2017 and 2018).  Anyways, during a presentation on the topic, one laboratory technologist told me that in her laboratory staff would sometimes, create a report, but put another staff persons name on it, NOT because they were afraid of repercussions of reporting, but because it was considered as SAFE MISCHIEF!!

Anyways, the reason that I have picked this up is because Just Culture is about to go international in a big way because the International Organization for Standardization (ISO) has just published a new standard ISO 7101:2023 entitled "Healthcare organization management — Management systems for quality in healthcare organizations — Requirements" which is predicated on these organizations (mostly hospital) embracing (or requiring) the use of Just Culture as the foundation of hospital environment and safety.  

Maybe this will happen, but it certainly won't happen over night.

More on this later.

M

Feels Good To Be Back.