Dennis Quaid and Medical Errors

On the drive to work today I listened to an interview on CSPAN's Washington Journal with a doctor based in Texas and actor Dennis Quaid.  Nearly a year ago, Quaid and his wife Kimberly were in the room when their newborn twins were given a dose of heparin that was 1,000 times the appropriate dose.  At 1:00 today Quaid and the doctor were to speak here in Washington at the National Press Club, in order to call attention to the release of a 500-page report on accumulated best practices in the avoidance of catastrophes.  A few themes that should be very familiar to HRO researchers:

1. It's not bad people, it's bad systems.  Quaid and the doctor were very good at praising performers within the systems and emphasizing that the 98,000 deaths per year identified by the Institute on Medical Organizations report from 1999 were a product of flawed systems, not evil people.
2. There are cross-industry lessons to be learned.  Quaid and the doctor referred several times to the fact that their friendship and their work was accelerated by the fact that they are both pilots.  They called for a National Transportation Safety Board for medicine. They noted that the nurses' "Five Rights" -- right patient, right prescription, right dosage, right time, and right method -- was a low-cost and helpful checklist that can reduce errors.  I kept waiting for them to recognize Chris Hart's "near-miss" data set as one of the things that could be transferred between industry contexts, but didn't hear that mentioned.
3. Awareness is important. They talked frequently about how little people care about medical errors until it affects them directly, and Quaid's twins' experience -- and his celebrity -- put "wind in the sails" of the project.  I suppose that Katie Couric will be talking about Quaid's project in a couple of hours on the evening news, and USA Today might have an article on the event tomorrow morning -- and it's a little sad that the American public has the attention span of a baby monkey -- but perhaps we can learn to leverage celebrity in the service of high-reliability better than we have in the past.

If I ever get an intern to help me with this blog, this would be a good place to put a link to the CSPAN video on Washington Journal on April 12, 2010, this would be a good place to put a link to the National Press Club event on April 12, 2010; and this would be a good place to put a link to media coverage of the event.  Quick core dump on HRO and medical error:

1. Kathie Sutcliffe co-edited a book with the title Medical Error several years' ago.
2. George Washington University doctoral student Kip Rollins is finishing a strong dissertation on team-based cardio surgical teams and the structuring actitivities that take place in them.
3. I'm a huge fan, recently, of a Katherine Klein et al. article in Administrative Science Quarterly on Trauma Resuscitation Units and the process of "dynamic delegation." 
4. And Amy Edmondson's research on cardio surgical teams learning to collaborate even more tightly than before due to a new surgical procedure is very impressive at driving home the importance of "psychological safety" in team cultures.
5. Finally, for now, Jenny Rudolph's dissertation data on anaesthesiology residents' leadership of teams in response to a complex 25-minute simulation convinces me that individuals do not have the cognitive bandwidth to solve wickedly complex problems, and teams can be built to be smart enough to accomplish those tasks.