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Systems thinking: Tap into staff creativity to unleash innovation



From the October 3, 2001 issue

Last week, a letter to the editor was published in the New England Journal of Medicine (Landrigan C. Preventable deaths and injuries during magnetic resonance imaging. N Engl J Med. 2001;345:1000-1) from a physician who suggested using metal detectors to prevent the risk of injuries from metal objects during magnetic resonance imaging (MRI). Unfortunately, his suggestion was spurred by the recent tragic death of a six-year-old child in New York who suffered a skull fracture and intracranial hemorrhage after an oxygen tank was pulled by the magnet into the machine at high speed.

As noted by the author, injuries from undetected or misplaced metal objects (e.g., IV drug poles, sandbags containing metal filings, defibrillators, wheelchairs, etc.) brought into MRI exam rooms are not uncommon. Yet, staff training and patient questionnaires to detect metal implants remain the most common methods used to prevent such incidents.

In fact, education has been healthcare's bread and butter for preventing errors and injuries. And while education may prevent some errors, its success is limited because it relies heavily upon human memory and vigilance. More to the point, education alone fails to change the system in a way that would make it impossible for people to make mistakes.

More effective solutions require systems thinking. The suggestion to use highly sensitive walkthrough metal detectors (which are available commercially for about $2,000-$5,500 and require minimal maintenance) to prevent accidental introduction of a metal object into a MRI exam room is an excellent example of systems thinking. This coupled with staff education and patient screening has a high likelihood of preventing injuries. But how did the physician come up with such a powerful suggestion? In retrospect, it seems so obvious. Yet systems thinking is not as easy as it seems.

Our history of errors with potassium chloride concentrate for injection in patient care units demonstrates this very well. Until systems thinking prevailed, many organizations relied upon staff education and manufacturer label warnings to prevent administration of potassium chloride concentrate without proper dilution. Although lessened, errors persisted until the pharmaceutical industry manufactured premixed solutions, physicians standardized potassium replacement therapy to maximize use of commercially available solutions, and vials of potassium chloride were removed from patient care units. Unfortunately, it took years for the healthcare industry to come up with and implement such an effective system-based solution that now seems so simple and intuitive.

To become more proficient at systems thinking, multidisciplinary teams must openly discuss medication errors and refuse to settle for old familiar (and ineffective) ways of solving problems. If education is identified as an error reduction strategy, we can't stop there. Instead of just building inspections into processes to detect errors before they reach patients, we need to find ways to actually prevent them. We must always ask, "Are there ways to make it impossible, not just unlikely, for people to make such a mistake?" Systems thinking is the key needed to bridge the gap between understanding the causes of errors and selecting error reduction strategies that have the greatest likelihood of success. With practice and a little creativity, we can become more skillful and innovative in identifying system-wide strategies that work continuously and automatically to prevent errors and injuries.

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