Wednesday, March 10, 2010

Positive ID

Working in a hospital, I have become very sensitized to the issue of proper identification of patients. Like other places, we require affirmative redundant identification by the patient before histories are taken, procedures are undertaken, and drugs are administered. For example: "What is your name?" "What is your birthday?" Not: "Are you Mary Smith, born on April 15, 1945?"

All this has made me more alert in other venues. This morning, I approached the American Airlines counter to check a piece of luggage. It is early on a quiet day, and there are no other people waiting in line. No pressure. I hand the agent my pre-printed boarding passes and my driver's license.

"That will be $20 for the luggage," she says.
"I thought I was exempt because I am an Aadvantage Gold member," I reply (while silently noting that the sign on the counter says $25, and not $20.)
"Well, I'll just waive it," she says.

She hands me a new boarding pass, with "Steven Levy" on it and my luggage receipt, which says "ORD" instead of "SFO."

"But I am going to San Francisco, not Chicago. And this boarding pass does not have my name on it."

"What is your name?" she says with a bit of annoyance, although she still has not returned my license. I tell her.

She reissues the boarding pass and luggage receipt.

I review both very carefully. And I wait until I see the luggage tag securely fastened to my suitcase.


e-Patient Dave said...

And this is a whole different aspect of "If air travel worked like healthcare," per the video you posted recently.

Mujib said...

Keep Spirit and be the best........chayo, i'm beginner

Anonymous said...

So you would have been without clothes, and if your plane crashed you would not have been (correctly) on the passenger manifest. These things always make me wonder how they are maintaining their airplanes if they can't do the simple things.....oh wait, they all outsource maintenance, so they have no idea!

Sarah said...

At the recent HIMSS conference, "Sully" Sullenberger spoke. He compared the airline industry error rates to the healthcare industry rate of errors and said healthcare could learn from the airlines.

But it struck me that his airline statistic was only catastrophic errors, whereas healthcare figures include any identified errors whether or not there was a negative outcome. If you counted the stupid little errors the airlines make, I bet we'd see that healthcare is at least as good!

e-Patient Dave said...

Sarah, the industry figure Sully quoted was the IOM's 42,000-98,000 *deaths* per year from preventable medical errors. That's 115-268 deaths per day, which is equivalent to a plane crash with no survivors. That's not counting non-lethal harms.

Today reading a chapter in Steven Spear's quality improvement book "Chasing the Rabbit" I learned that that's only half of it - it doesn't count medication errors, I believe. (I don't have the book anymore.) Spear also documents that for every actual death there are 5-10 near misses, and for every near miss there are 5-10 errors that get caught before it gets perilous, etc. Bottom line, he said, for every death, it's reasonable to figure that there were around 200 to 1,0000 earlier episodes where a problem happened but it didn't get fixed then and there.

He gives a very detailed account of how similar policies and behavior patterns lead to NASA's Challenger disaster.

And that's the work of Lean: to never stop grabbing every opportunity to improve, even if there's no apparent immediate crisis - literally, "before we kill someone."

Anonymous said...

Dave makes a very good point; it is also true that most catastrophic errors in medicine turn out to be a chain of small errors which, had any one been caught, would have aborted the catastrophe. These errors are not always only on the part of caregivers; I recall one ER episode 20 years ago where the patient, a frequent traveler to malaria-endemic regions, neglected to tell the docs that he had failed to take his prophylaxis. This, along with about 3 other individual errors on the part of the ER and the lab, caused a delayed diagnosis and hence his eventual death from fulminant falciparum malaria ("blackwater fever") As you see, these errors stick in our minds forever...nad prove Dave's point that you never know which small error prevention might save a life.

nonlocal MD

nonlocal MD

Anonymous said...

Technical correction: it was cerebral malaria in the patient I cited above, not specifically blackwater fever.


RalfLippold said...

Paul, I just imagine being in a similar position standing at a counter and encounter your excperience.

Crazy, that errors are so easy to produce in daily life. In this case you have been already alerted. Other people wouldn't have noticed directly, probably only when boarding or on touch-down at their destination. By then the real and root-cause would not be easily to detect.

Transparency in the value stream -also visible to the client, customer or patient- is what makes processes better over time. As more eyes see what is going wrong or could go wrong.

Thanks for sharing such stories that could happen to anyone of use as well!