What healthcare can learn from the energy industry about catching errors
Medical errors are now the third leading cause of death in the United States. If this were an Olympic event, that would be a bronze medal.
Unfortunately, this is not a statistic the medical community is proud of, nor is it one that can be ignored. Medical error reduction and prevention is a challenge being addressed across all aspects of healthcare.
To address the issue, it’s essential to understand the problem and what constitutes a medical error; a few of the most common errors include:
- Medication errors
- Anesthesia errors
- Hospital-acquired infections
- Missed or delayed diagnosis
- Avoidable delay in treatment
- Inadequate follow-up after treatment
- Inadequate monitoring after a procedure
- Failure to act on test results
The final article in our series on cross-industry learnings has us focusing on energy – specifically nuclear energy. By carefully studying these errors, as well as how similar industries manage mistakes, we can learn to prevent them in the future.
Like healthcare, nuclear power companies need to be highly reliable organizations. Atomic reactors are some of the earth’s most sophisticated and complex energy systems. However, any complex system, no matter how well designed and engineered, cannot be deemed failure-proof. Given the high human, environmental, and financial cost of a radioactive leak, these companies go to great lengths to bring errors to zero. Here are some approaches from the energy sector that the healthcare industry can learn from and apply to address medical errors.
Catch the issue before it becomes a meltdown
Nuclear infrastructure safety is all about defense-in-depth, a strategy that leverages multiple security measures to protect or prevent errors. This approach works to limit the chance that any small or even large issue becomes a dangerous nuclear meltdown. At a nuclear power plant, depth is the physical distance between radioactive materials and civilians and the depth of the backup plan. Nuclear meltdowns are avoided by the rods that encase the reactor’s uranium fuel, the massive steel reactor vessels and cooling systems that hold and cool the rods, and the several feet of steel-reinforced concrete that houses the reactor vessels. If standard equipment malfunctions, multiple redundant safety equipment options in place. In thinking about healthcare, there are not as many double checks or backup security options applied in clinical practice.
A second set of eyes approach
While safeguards are critical for limiting incidents, errors do occur and must be understood to prevent them in the future. As one nuclear energy researcher stated, “the problem with new reactors and accidents is twofold: scenarios arise that are impossible to plan for in simulations, and humans make mistakes.” To address this, the nuclear power industry has gone to great lengths to understand these human mistakes and learn from them.
For example, many stakeholders review each reactor to ensure safety. First, the U.S. Nuclear Regulatory Commission (NRC) oversees plant safety and security for commercial U.S. nuclear reactors. One oversight initiative is the Resident Inspectors Program, where two individuals are stationed at each plant, daily auditing people, processes, and technology to prevent errors. Furthermore, the nuclear power industry conducts peer reviews of plant operations through the Institute of Nuclear Power Operations, the International Atomic Energy Agency, and the World Association of Nuclear Operators.
Healthcare has the radiology peer review process in which health systems randomly double-check their work to ensure no diagnostic medical error is overlooked and subsequently falls through the cracks. Unfortunately, only 3-5% of the total imaging volume at a hospital gets the safety net second read, leaving over 90% of all radiology images with only a single read.
Another factor in the medical error cycle is that hospitals haven’t fully bought into a streamlined incident reporting process or a blame-free culture. As a result, 40% of U.S. hospitals are not leveraging the numerous benefits of Patient Safety Organizations (PSOs). PSOs allow for the safe identification of errors that lead to quality and safety issues and enable the next step of developing interventions to prevent and mediate errors.
Pioneering healthcare leaders can learn from the nuclear energy industry and work within their hospitals to implement redundant checks across the entire patient journey. The use of technology, such as AI for a second read across all imaging scans will be critical in reducing medical errors.
Health systems can leverage these cross-industry learnings by asking a few questions:
- What is your health system’s defense-in-depth strategy for limiting medical errors?
- Does your health system have a radiology second read program in place that assesses all images or just the routine 3-5% that fall within the peer review process?
- Does your hospital a member of a PSO? If yes, how is your hospital using the program to learn and change behavior going forward? If no, is joining a PSO something your hospital should consider and research?
How is your healthcare system addressing medical errors?
Drop us a note and share your learnings.