WBB's Thought Leadership

The Problem of Rare Human-Factor Quality and Safety Events

February 2

Quality and Safety issues that occur in hospitals include taking pictures of patients without their permission, homicide, and illicit drug use. These are rare events but have large impacts.

WBB Take:  The focus of quality management (QM) in healthcare is often on operational risks, such as variations in processes, medical errors, and low value care. However, incidents of extreme human behavior are outliers in quality and safety that should nevertheless be considered due to the large effects they may have. Policies, processes, and procedures should be able to reduce the risk of extreme, although perhaps very unlikely, human behaviors.
In this article, a retired surgeon and surgical department chairman and residency program director, describes three examples of extreme behavior in a hospital workplace. All three are “never events” that are unlikely to ever be topics in a QM discussion or planning session. These examples may indeed be highly unlikely events, but yet they occurred, and therefore require the quality professional to consider how the risk of such incidents could be reduced, and how the effects might be mitigated. Human-factor risks to quality and safety can include extreme behavior, and Human Resources (HR) processes at healthcare facilities should be integrated with QM to reduce the risks.
Whether there are reliable leading indicators of extreme human behavior is a topic for a different author, and I leave the reader to reflect on whom that may be.

Cited by Matthew Loxton

Excerpt: “Here are some tips from an experienced former provider—me.”


“Nude Pictures…
Do not take nude pictures of fellow employees. A woman unit secretary in the operating room of a hospital in Greene County, Pennsylvania said while she was anesthetized for an incisional hernia repair, an operating room nurse took photographs of her naked body and later showed them to several coworkers.
The patient, known only as Jane Doe, has filed suit against the hospital, several of its employees, and the surgeon who operated on her because he did not report the nurse who took the pictures to hospital administration.
According to the local newspaper, the OR nurse was fired after Ms. Doe reported the incident, [...].”

“Murder…
Do not [allegedly] murder a patient. An anesthesiologist was arrested and charged with murder in December because his patient, who was an orthopedic surgeon, had a cardiac arrest after undergoing plastic surgery at a Beverly Hills clinic. The Los Angeles Times story about the incident reported the patient died of an overdose of Demerol, a narcotic rarely used these days, and police say the anesthesiologist [allegedly] injected himself with drugs during the case.”

“Overdose…
Do not overdose at work. A nurse at a nursing home in Western Pennsylvania overdosed while on duty back in April. A Pittsburgh television station said an investigation showed that patients were not receiving pain medication that had been ordered. Police think the nurse was charting that the drugs had been given without actually doing so.”

Source: Physician’s Weekly


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