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How lack of Standardisation can take a life.

By Dennis Keay

When your child is in a hospital emergency room, fighting for life, you don’t want the doctor to turn her back and walk OUT of the room.  It’s worse still when that emergency was caused by a doctor in the first place. This was the situation I found myself in when I took my daughter, Melissa (Mel), into a well know public hospital in Victoria.

Question: Why did she need to go into emergency in the first place?

Answer: Because a doctor had administered medicine to her that was not meant for children. She subsequently had an allergic reaction, causing her tongue to swell, cutting off her air supply.

Question: Why, when she was in the emergency room, did a different doctor leave the room while Mel was struggling to breathe?

Answer: To find an oxygen mask!  Really, in a major public hospital?  Yes!! 

I could hardly believe what was happening. I followed the doctor out of the room because something needed to be done for Mel, urgently! There wasn’t time to waste! The doctor found a mask and returned to the room. Then she connected the mask to the oxygen supply, and then started to DISCONNECT the oxygen supply from the wall instead of turning on the oxygen supply via the thumbwheel at the bottom of the flow-control device.

It was my worst nightmare, but it was actually happening. My daughter’s life was at stake and the doctor was disconnecting the oxygen supply from the wall!  I stopped her and turned the thumbwheel to start the oxygen flowing.

I’m so thankful that Mel was soon given an injection that rapidly reversed the swelling of her tongue, leading to a happy outcome, and I even took a couple of photos as she was recovering in the emergency room.  But, being a person who needed to understand what happened in there, I delved deeper into cause-and-effect.

Melissa, recovering after the injection to counter swelling of the tongue

What I found was:

  1. The young doctor was an inexperienced intern–a physician in training who had completed a medical degree, but not licensed to practice medicine unsupervised. She was no doubt panicking on the inside.
  2. The oxygen flow control in our emergency room was different from that in the other emergency cubicles.
    • The others all had a single oxygen supply outlet, with a flow control and mask attached.

      This room had two flow-controls, but only one had a tube and mask attached.

      • The doctor only noticed the one that didn’t have a tube and mask attached. That’s why she went out of the room (needlessly), to search for another mask.
      • The flow control that did have the mask attached was quite different from others in the Emergency Department.

        The flow control in this room had a silver thumbwheel at the top to adjust the flow. The flow controls in the other emergency cubicles (that the intern was familiar with) had a white plastic knob at the bottom to turn to adjust the flow.

        She was looking for a white plastic knob at the bottom to turn, and the closest thing that resembled that was the white plastic coupling that connected the flow control to the oxygen supply at the wall. In her ‘panic’ she was trying what she could…but that was disconnecting the oxygen source all together.

There’s lots of lessons to be learned from this emergency room case study, and here are just a few:

  1. An ounce of prevention is worth a pound of cure. The situation should never have occurred in the first place. Make sure you ‘get it right first time’. Not doing so can lead to enormous costs, including life.
  2. Highly intelligent, well-educated and well-meaning people (doctors in this case) can do some apparently dumb things when under stress and time-pressure, particularly when in an unfamiliar environment.

    Don’t just assume that because someone has great credentials that they’re infallible.

  3. System design is important:
    • ‘Simple things’ such as lack of equipment Standardisation can confuse people.

      We are Visual Creatures … as evidenced by the intern trying to turn ‘a white knob’, simply because a white knob was what she was accustomed to looking for.

      >> Smart design of systems takes advantage of the fact that we
      are visual creatures! (Colour coding is part of this, but when designing systems with colour coding, you need to take into account that approximately 8% of males are colour blind.)

  1. It’s very easy to blame people, but we need to step back and have a look at the systems in which they are working. In my experience, it’s very difficult for good people to do a good job in a broken system. Conversely, a well-designed system enables average people to do a great job.

    Before blaming people, always look for root-causes and system failures. It’s usually the system that is at fault, and very often, the people working in that system are very frustrated because, try as they may, the outcome is much worse than they are striving for.

This case study reminds me so much of many of the businesses I visit.  They wonder why, when they strive so hard, they’re not getting the results that they desire. The reason is usually quite obvious to me:  Their system is perfectly designed to produce the results they are getting!  That goes for every part of the system from recruitment all the way through.

So, if you’re not satisfied with the results you’re getting, look to ‘re-designing your system’, or at least certain aspects of it.