We are killing babies with our resuscitation equipment and our approach to safety. Each individual case seems isolated, but they add up over the world, and over time. All of the accidents on this list have one thing in common: the hose that was supposed to deliver oxygen to a patient was delivering the wrong gas. For Australians, the recent death in Bankstown-Lidcombe Hospital is close to home, and suggests an opportunity to improve accident prevention in our hospitals.
The approach taken by the NSW Ministry of Health in relation to this terrible accident was to perform an urgent root-cause analysis, and to take action to address the root cause. In a perfectly sensible report, they note that this accident would not have happened if engineering work on the gas pipes had been performed and tested correctly. The weakness of this approach is that it assumes that the accident had one cause.
Root-cause analysis comes from manufacturing, and is a very important part of the Toyota Production System (‘Lean’ manufacturing is an effort to bring the Toyota Production System to English-speaking countries). When applying the TPS or Lean, we must remember something vitally important: TPS aims to make failures as obvious as possible, and it does this by amplifying the impact of process failure. The end result is an extremely efficient, low-cost and reliable system.
The road to that end result is paved with shutdowns of the entire factory, and massive impacts from the tiniest changes. (A visitor to a Japanese electronics factory once moved a container of components two meters away from where it was kept. The entire human-operated production line was halted until the container was put back where it came from.) Can we afford to think of hospitals as factories? Is it ethical to shut down an emergency department for an hour, so that the resulting root-cause analysis will result in a 0.5% increase in efficiency?
If a hospital is not a factory, then perhaps safety improvement is not the same as quality improvement. Compare this aviation accident description with the Bankstown root-cause analysis.
There are important similarities: a careful examination of the facts, using witnesses and material evidence, and a clear statement of the cause of the accident (‘faulty engineering work’ in the hospital, ‘fast, low approach’ at Sligo airport). The difference is in the structure of the question: there’s a world of difference between “Why did this accident happen?” and “How could we have prevented this accident?”
Accident prevention is a much broader objective than error prevention. We take it for granted that ‘errors cause accidents’, and our instincts are to eliminate errors so that we can eliminate accidents. The aviation industry has learned that pilots are human beings. They don’t have to amplify their errors (like factories do) in order to see them as ‘worth solving’. While most of us assume that “errors = accidents”, aviation knows that “errors - safeguards = accidents”.
By obsessing over error reduction (via root-cause analysis), we miss opportunities to increase safeguards.
The recommendations flowing from the accident at Sligo Airport addresses the root cause, recommending that the airport install an Instrument Landing System to reduce the chance of a ‘fast, low approach’. That report also recommends increasing the runway overrun area, to reduce the danger of a ‘fast, low approach’.
Interestingly enough, we know that gas contamination isn’t always caused by faulty engineering work. The same incident (at Royal Prince Alfred) tells us that gas contamination can be detected and remedied without killing anyone. In the Royal Prince Alfred incidents, anaesthetic machines were in use that automatically report the concentration of oxygen being delivered to the patient. In the Bankstown accident, there was no analyser, and no way to know that the babies were being suffocated until their blood oxygen levels fell.
Back-of-the envelope calculations suggest that the cost of fitting oxygen analysers to the thousand neonatal resuscitation trolleys in New South Wales would be around half a million dollars. If a hospital is a factory, then that’s a wasted investment — all we need to do is to wait for the next baby to die, and that will show us the next root cause we need to address. If a hospital is not a factory, then we need to consider investing in safeguards.