{"id":1341,"date":"2012-03-17T13:24:09","date_gmt":"2012-03-17T13:24:09","guid":{"rendered":"http:\/\/www.saasoft.com\/blog\/?p=1341"},"modified":"2012-03-17T13:24:09","modified_gmt":"2012-03-17T13:24:09","slug":"never-events-near-misses-and-niggle-nailing","status":"publish","type":"post","link":"https:\/\/hcse.blog\/?p=1341","title":{"rendered":"Never Events and Nailing Niggles"},"content":{"rendered":"

\"\"<\/a>Some events should NEVER<\/strong> happen – such as removing the wrong kidney; or injecting\u00a0an\u00a0anti-cancer drug designed for a vein\u00a0into\u00a0the\u00a0spine; or\u00a0sailing\u00a0a cruise ship over a charted underwater reef; or\u00a0driving a bus full of sleeping school children into a concrete wall.<\/p>\n

But\u00a0 these\u00a0catastrophic irreversible and tragic Never Events do keep happening\u00a0– rarely perhaps – but\u00a0persistently.\u00a0At the Never-Event\u00a0investigation the Finger-of-Blame goes looking\u00a0for the incompetent culprit while the innocent victims call for compensation.<\/p>\n

And after the smoke has cleared\u00a0and the pain of loss has dimmed another\u00a0Never-Again-Event happens – and then another, and then another. Rarely perhaps – but not\u00a0never.<\/p>\n

Never Events are\u00a0so\u00a0awful and emotionally charged that we remember them and we come\u00a0to believe that they are not rare and from that misperception we develop a\u00a0constant nagging\u00a0feeling of fear for the future. It is\u00a0our fear that erodes our\u00a0trust which leads to the\u00a0paralysis that\u00a0prevents us from acting. \u00a0In the globally tragic event of 9\/11 several thousand innocents victims died while the world watched in horror. \u00a0More innocent victims than that die needlessly\u00a0every day<\/strong> in high-tech hospitals from avoidable errors – but that statistic is never shared.<\/p>\n

The metaphor that is often used is the Swiss Cheese –\u00a0the sort on cartoons with lots of holes in it.\u00a0The cheese represents a quality check –\u00a0a barrier that catches\u00a0and corrects mistakes before they cause irreversible damage. But the cheesy check-list is not perfect; it\u00a0has\u00a0holes in it.\u00a0 Mistakes slip through.<\/p>\n

So\u00a0multiple\u00a0layers of cheesy checks\u00a0are added in the hope that the holes in the earlier\u00a0slices will be covered\u00a0by\u00a0the cheese in the later\u00a0ones\u00a0– and\u00a0our experience\u00a0shows that this multi-check\u00a0design does\u00a0reduce the number of mistakes that get through.\u00a0But not completely.\u00a0And\u00a0when, by rare chance,\u00a0holes in each slice\u00a0line up then the\u00a0error\u00a0penetrates all the way through\u00a0and a Never Event becomes a Actual Catastrophe.\u00a0 So, the\u00a0typical\u00a0recommendation\u00a0from the after-the-never-event\u00a0investigation is\u00a0to add another\u00a0layer of cheese\u00a0to the\u00a0stack –\u00a0another\u00a0check on the list\u00a0on top of all the others.<\/p>\n

But the cheese is not durable:\u00a0it deteriorates over time with the incessant\u00a0barrage\u00a0of work and the pressure of increasing demand.\u00a0The holes get bigger, the cheese gets thinner, and new holes appear. The inevitable outcome\u00a0is the opening up of unpredictable, new\u00a0paths\u00a0through the cheese to a Never Event;\u00a0more\u00a0Never Events; more\u00a0after-the-never-event\u00a0investigation; and more slices of\u00a0increasingly expensive and complex cheese added to the tottering, rotting\u00a0heap.<\/p>\n

A drawback of the Swiss Cheese metaphor\u00a0is that\u00a0it\u00a0gives the impression\u00a0that\u00a0the slices are static and each cheesy check has a consistent position and persistent\u00a0set of flaws in it. In\u00a0reality this is\u00a0not the case – the\u00a0system behaves as if the\u00a0slices and the holes are moving about:\u00a0variation is jiggling ,\u00a0jostling and wobbling the whole\u00a0cheesy edifice.<\/p>\n

This wobble does not increase the risk of a Never Event\u00a0 but\u00a0it prevents the subsequent after-the-event\u00a0investigation from discovering the\u00a0specific conjunction of holes\u00a0that caused it.\u00a0The Finger of Blame cannot find a culprit\u00a0and the cause is labelled a\u00a0“system failure”\u00a0or\u00a0an\u00a0unlucky individual is implicated and named-shamed-blamed\u00a0and sacrificed to the Gods of Chance on the Alter of Hope! More often new slices of KneeJerk Cheese are added in the desperate hope of improvement – and creating an even greater burden of back-covering bureaucracy than before – and paradoxically increasing the\u00a0number of holes!<\/p>\n

Improvement Science offers a more rational, logical, effective and efficient approach to dissolving this\u00a0messy, inefficient and\u00a0ineffective safety design.<\/p>\n

First it recognises that\u00a0to prevent a Never\u00a0Event then no errors should reach the last layer of cheese checking – the last opportunity to block the\u00a0error trajectory.\u00a0An error that penetrates that far\u00a0is a Near Miss and these\u00a0will happen more often than Never Events so they are the key to understanding and dissolving the problem.<\/p>\n

Every Near Miss that is detected should\u00a0be reported and investigated immediately<\/strong> – because that is the best time to\u00a0identify the hole in the previous\u00a0slice – before it wobbles out of sight. The goal of the investigation is understanding not accountability. Failure to report a near miss;\u00a0failure to investigate it; failure to learn from it; failure to act on it; and failure to monitor the effect of the action\u00a0are all errors of omission (EOOs) and they are the worst of management crimes.<\/p>\n

The question to ask is “What error happened immediately before the Near Miss?<\/em>” \u00a0This\u00a0event\u00a0is called a Not Again<\/strong>. Focussing attention on this Not Again and understanding what, where, when, who and how it happened\u00a0is the\u00a0path to preventing the\u00a0Near Miss and\u00a0the\u00a0Never Event.\u00a0 Why is not<\/strong> the question to ask – especially when trust is low and cynicism and fear are high – the question to ask is “how”.<\/p>\n

The first action after Naming the Not Again is to design a counter-measure for it – to plug the hole – NOT to add another slice of Check-and Correct cheese! The\u00a0second necessary action is to treat that\u00a0Not Again as a Near-Miss and to monitor it so\u00a0when it happens again\u00a0the cause can be identified. These common, every day, repeating causes of Not Agains are called Niggles;<\/strong> the hundreds of minor irritations that we just accept as inevitable. This is where the real work happens – identifying the most common<\/em> Niggle and focussing all attention on nailing it! Forever. \u00a0Niggle naming and nailing is everyone’s responsibility – it is part of business-as-usual – and if leaders do not demonstrate\u00a0the behaviour and set the expectation then followers will not do it.<\/p>\n

So what effect would we expect?<\/p>\n

To answer that question we need a\u00a0better metaphor than our static stack of\u00a0Swiss cheese slices: we need something more dynamic – something like a\u00a0motorway!<\/p>\n

\"\"<\/a>Suppose you were to\u00a0set out\u00a0walking across a busy motorway with your eyes shut and your\u00a0fingers in your ears – hoping to get to the other side without being\u00a0run over.\u00a0What is the chance that you will make it across safely?\u00a0 It depends on how busy the traffic is and how fast you walk – but say you have a\u00a050:50 chance of getting across\u00a0one lane safely (which is the same chance\u00a0as tossing a\u00a0fair coin and getting a head) –\u00a0what is the chance that you will get across all six lanes safely? The answer is the same chance as tossing six\u00a0heads in a row: a\u00a01-in-2 chance of\u00a0surviving the first lane (50%), a 1 in 4 chance of getting across two lanes (25%), a 1 in 8 chance of making it across three (12.5%)\u00a0…. to a 1 in 64 chance of getting across all six (1.6%). Said another way that is\u00a0a 63 out of 64 chance of being run over somewhere which is\u00a0a 98.4%\u00a0chance of failure – near certain death! Hardly a Never Event.<\/p>\n

What happens to\u00a0our risk of being run over\u00a0if the traffic in just one lane\u00a0is\u00a0stopped and that lane is now\u00a0100% safe to cross? Well\u00a0you might think that it depends on which lane it is\u00a0but it doesn’t – the risk of failure\u00a0is now\u00a031\/32\u00a0or\u00a096.8% irrespective of which lane it is – so not much\u00a0improvement apparently! \u00a0We have doubled the chance of success though!<\/p>\n

Is there a better improvement strategy?<\/p>\n

What if we work collectively to just reduce the\u00a0flow\u00a0of Niggles in all the lanes\u00a0at the same time\u00a0–\u00a0and suppose we\u00a0are all able to reduce the risk of a Niggle in our lane-of-influence\u00a0from\u00a01-in-2 to 1-in-6. How we do it is up to us.\u00a0To illustrate the benefit we\u00a0replace our coin with a six-sided die (no pun intended) and\u00a0we only “die” if we throw a 1.\u00a0 What happens to our pedestrian’s probability\u00a0of survival?\u00a0The chance of\u00a0surviving\u00a0the first lane is now\u00a05\/6 (83.3%), and both first and\u00a0second 5\/6 x 5\/6 = 25\/36 (69%.4) and\u00a0so on to\u00a0all six\u00a0lanes which is 5\/6 x 5\/6 x 5\/6 x 5\/6 x 5\/6 x 5\/6\u00a0= 15625\/46656 = 33.3% which is a lot better than our previous\u00a01.6%!\u00a0 And what if we keep plugging the holes in our bits of the cheese\u00a0and we increase our individual lane success rate to 95% – our pedestrians probability\u00a0of survival is now 73.5%. The\u00a0chance of a catastrophic event becomes less and less.<\/p>\n

The arithmetic may be a bit\u00a0scary\u00a0but the message is clear: to prevent the Never Events we must reduce the Near Misses and to to do that we investigate every Near Miss and expose the Not Agains and then use them to Name and Nail all the Niggles. \u00a0And we have complete control over the causes of our commonest Niggles because we create them.<\/p>\n

This strategy\u00a0will improve the safety of our system. It\u00a0has another positive benefit – it will\u00a0free up\u00a0our Near Miss investigation team\u00a0to do something else: it frees them to assist in the re-design the\u00a0system so that Not Agains cannot happen at all\u00a0– they\u00a0become Never Events too –\u00a0and the earlier in the path that safety-design happens the better – because it renders the other layers of check-and-correct cheesocracy\u00a0irrelevant.<\/p>\n

Just imagine what would happen in a real system if we did\u00a0that …<\/p>\n

And now try to justify not doing it …<\/p>\n

And now consider what an individual, team and organisation would need to learn to do this …<\/p>\n

It is called Improvement Science.<\/p>\n

And learning the Foundations of Improvement Science in Healthcare (FISH<\/a>) is one place to start.<\/p>\n

\"fish\"<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

Some events should NEVER happen – such as removing the wrong kidney; or injecting\u00a0an\u00a0anti-cancer drug designed for a vein\u00a0into\u00a0the\u00a0spine; or\u00a0sailing\u00a0a cruise ship over a charted underwater reef; or\u00a0driving a bus full of sleeping school children into a concrete wall. But\u00a0 these\u00a0catastrophic irreversible and tragic Never Events do keep happening\u00a0– rarely perhaps – but\u00a0persistently.\u00a0At the Never-Event\u00a0investigation … <\/p>\n

Continue reading “Never Events and Nailing Niggles”<\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[5,15,21,35,42,45,48,49],"tags":[],"class_list":["post-1341","post","type-post","status-publish","format-standard","hentry","category-4n-chart","category-design","category-governance","category-reflections","category-how","category-what","category-trust","category-victimosis"],"_links":{"self":[{"href":"https:\/\/hcse.blog\/index.php?rest_route=\/wp\/v2\/posts\/1341","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/hcse.blog\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/hcse.blog\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/hcse.blog\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/hcse.blog\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=1341"}],"version-history":[{"count":0,"href":"https:\/\/hcse.blog\/index.php?rest_route=\/wp\/v2\/posts\/1341\/revisions"}],"wp:attachment":[{"href":"https:\/\/hcse.blog\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1341"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/hcse.blog\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=1341"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/hcse.blog\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=1341"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}