Several years ago I wrote an article about a process problem that we had at Langley AFB. Our bottles of saline and potassium hydroxide looked identical. On two separate occasions, nurses accidentally washed out a patient’s eye with potassium hydroxide because of the look alike bottles.
We found a different packaging for potassium hydroxide as a single dose vial. They no longer looked alike. So the error could not be made going forward.
As a Commanding Officer I learned that people did not do stupid things on purpose. Systems were often set up for them to fail. The potassium hydroxide is an example of a flawed system.
Part of that learning on my part was to not ask who was to blame for errors. My question always was: “What’s wrong with this process?”.
I retired in 1995. In 1996, the Joint Commission on Accreditation of Hospitals developed what they called a Sentinel Event policy.
A Sentinel Event is defined as: “A patient safety event that results in death, permanent harm or severe temporary harm.” Every hospital that has such an event is required to do what is called a Root Cause Analysis.
The first step is to define the problem. That means gathering general information about the event. It might include who was involved. It might include what was involved. It might include relevant circumstances.
The second step is to gather data related to the incident. It may involve reading the incident report. It may involve interviews of individuals involved. The goal is to identify contributing factors.
The third step is to look at factors related to the causation of the event. The goal is to identify fundamental reasons why the problem occurred.
The fourth step is to go through the information to see what the root cause was. For the example I used about the potassium hydroxide, the root cause was two look alike bottles. One had harmless saline. The other had harmful potassium hydroxide.
The fifth step is to implement solutions suggested by the gathered data. These solutions are then monitored to make sure they are working. When the first nurse put potassium hydroxide in the patient’s eye, she received a letter of counseling. That was not effective in stopping it from happening again. It was not really her fault. The system had failed her.
I bring this up now because in a recent interview someone asked Governor Abbott of Texas who was to blame for the flooding disaster. There is no “Who” involved. It will turn out to be system failures. The failures will not likely fall to any one individual. A root cause analysis will need to be done to put new processes into place.
Finding someone to blame might make everyone feel better that something was done. However, it is unlikely to provide a long term solution. It is not about those fault is it. It is about what’s wrong with this process.