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Friday, November 21, 2008

They walk the talk all the way to Japan: The healthiest response to a fatal medical error

I was privileged to hear a talk today by Dr. Gary Kaplan, the CEO of Virginia Mason Medical Center in Seattle. He described their long quality journey in using the Toyota system of lean production.

He spoke of a preventable death of a patient in 2004, and what the medical center has done to systematically prevent medical errors.

Mary L. McClinton had moved from Alaska to the Seattle area in 1996. She had dedicated her life to helping others, her family said. She was even adopted by the Tlingit tribe for her work as a vocational coordinator. She worked at the Greater Trinity Missionary Baptist Church in Everett, Washington, helping to find jobs for people with physical and mental disabilities.

Mary went to the hospital in 2004 for an eye procedure, and as she was sitting in a waiting room, a large picture, about 6 feet square, fell onto her head, and "knocked her silly," her son Gerald said. In the days afterward she felt dizzy, so he took her to an Everett hospital where a brain scan revealed a swelling in a blood vessel in her brain - an aneurysm.

Later, she came to Virginia Mason Medical Center for treatment for the aneurysm. The hospital had recently switched from a brown iodine-based liquid to a clear antiseptic for cleansing a patient's skin before and after procedures. During the procedure to treat the aneurysm, hospital staff would inject a clear marker dye into the patient's blood vessels to make them visible on X-rays. "At some time during the procedure, the clear antiseptic solution was placed in an unlabelled cup identical to that used to hold the marker dye," according to a hospital memo tracing the root causes of the error. The antiseptic, rather than the dye, was then mistakenly injected into a main artery that carried blood to Mary's leg.

The antiseptic solution was highly toxic when injected into a blood vessel: it blocked the flow of blood to her muscles, causing the leg to swell; her blood pressure dropped, her kidneys failed, and she suffered a stroke. She died soon afterward, in November 2004.

The hospital promptly took the unusual step of publicly explaining, and apologizing for, the error. The only way to improve patient safety, Dr. Kaplan said at the time, is to be "open and honest about our errors. ... You can't understand something you hide."

Since the error, the liquid antiseptic has been removed from the hospital and replaced with a swab on a stick. It's now impossible to mistake the clear liquid dye for the swab. This is an example of pokayoke – a safeguard that makes an error impossible.

Most of us try to suppress the memory of a big error. It's to the credit of Dr. Kaplan and his management team that they instead tried to use this awful error to stimulate their continued improvement. Indeed, the hospital has developed the Mary L. McClintock Award, and has made awards annually since 2006, to teams that have significantly improved safety in the Critical Care unit, the IV [Intravenous] Unit, and the Stroke Center, in the last three years.

Dr. Kaplan mentioned Mary in his talk this morning, but, appropriately, did not make her the centerpiece of his talk. The hospital's quality journey started before the error that killed Mary, and is far more system-wide than even the clinical functions that ripple around her care. Board members are now expected to join the CEO on trips to Japan to continue learning how to improve quality, using Toyota’s methods. Each Board meeting begins with a story by a patient or family member about an error. Staff on various teams have now participated in 500 intensive five-day sessions to redesign specific elements of the hospital's care.

Virginia Mason used several of the same elements that CareGroup (then a six-hospital system in eastern Massachusetts) did in its multi-year quality attempt to become the safest hospital to get medication in the world: The CEO very publicly led a high-profile multi-year broad project. Clinicians regularly discussed errors to learn from them. And well-grounded, proven change concepts provided the basis of the transformation.

Advice to people needing hospital treatment: Find a hospital that learns from its errors rather than hiding from them.

Read about another look-alike error.

Thanks to Nick Perry and Carol Ostrom for the source story in the Seattle Times of Nov. 25, 2004.

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