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.