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Resources for the "Business Case for a Learning-Based Approach to Errors"

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If you find these resources helpful and use any of them in your slide decks, handouts, etc., please include
From Jake Mazulewicz at reliableorg.com. Thanks.

BC1) The Northeast blackout of 2003

"All told, 50 million people lost power for up to two days in the biggest blackout in North American history. The event contributed to at least 11 deaths and cost an estimated $6 billion."

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BC2) The NOAA satellite that fell over

"While the turn-over cart used during the procedure was in storage, a technician removed twenty-four bolts securing an adapter plate to it without documenting the action. The team subsequently using the cart to turn the satellite failed to check the bolts, as specified in the procedure, before attempting to move the satellite. Repairs to the satellite cost US$135 million. Lockheed Martin agreed to forfeit all profit from the project to help pay for repair costs.”

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BC3) The nuclear kitty litter incident

"It exposed 22 people to radiation, shut down the underground facility for 35 months and cost the United States over a billion dollars. Heat and pressure had built up in the drum due to chemical reactions with an organic kitty litter, Swheat Scoop, which had been mistakenly added to it at Los Alamos National Laboratory, the birthplace of the atomic bomb."

 

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BC4) How one error cost Citibank $800 million

"Citibank, which was acting as Revlon’s loan agent, meant to send about $8 million in interest payments to the cosmetic company’s lenders. Instead, Citibank accidentally wired almost 100 times that amount, including $175 million to a hedge fund. In all, Citibank accidentally sent $900 million to Revlon’s lenders."

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BC5) To Err is Human -- medical errors lead to 44,000 - 98,000 deaths each year

"Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDS--three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems.

  • Some have challenged this study’s methodology and focus.

  • A similar 2014 study found that medical errors lead to over 250,000 deaths each year, making medical error the 3rd leading cause of death in the US.

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BC6) The $37 billion problem

"The global analyst firm IDC, in a 2008 white paper, examined human error in the form of “employee misunderstanding” and its financial impact on 400 U.K. and U.S. businesses...

 

It defined employee misunderstanding as actions by employees who have misunderstood or misinterpreted company policies, business processes, job functions—or a combination of the three.

The average cost of this misunderstanding, at a company with 100,000 employees, is $62.4 million per year. Combined, U.K. and U.S. enterprises are losing an estimated $37 billion every year. The cost of intangibles—like reputation or customer trust—could have even greater consequences.
"

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BC7) Why Teams Don't Learn from Their Mistakes (and How to Change That)

"In 2002, Dr. Gary S. Kaplan, the recently appointed chief executive of the Virginia Mason Health System in Seattle, visited Japan with some fellow executives. He wanted to see how organizations outside the health care sector did things. At a Toyota plant, Kaplan had a revelation... If a culture is open and honest about mistakes, the entire system can learn from them.”

Since the new approach was taken, the hospital has seen a 74% reduction in liability insurance premiums."

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BC8) The Michigan Model: Medical Malpractice and Patient Safety at Michigan Medicine

(LOTS of links within)

  • "The number of claims and lawsuits has dropped dramatically. In July, 2001 [before we launched our Open Reporting initiative] we had more than 260 pre-suit claims and lawsuits pending... We currently have just over 100.

  • Our legal costs appear to be down dramatically, with the average legal expense per case down by more than 50 percent since 1997.

  • The severity of our claims is rising far less rapidly than the national average.

  • Our malpractice premiums are practically level, despite increases in our clinical business."

Our approach can be summarized as:

Apologize and learn when we’re wrong,

explain and vigorously defend when we’re right,

and view court as a last resort.”

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BC9) USS Benfold -- from the worst ship in the Navy to the best, in 20 months

  • When Mike Abrashoff became Captain of the USS Benfold, he replaced traditional “command & control” leadership with trust, Psychological Safety, and a Learning-Based Approach.

  • Within 20 months:

    • retention rose from 28% to 100%

    • safety incidents dropped from 31 to 2

    • costs dropped to 25% below budget (p.28)

    • and the crew won the award for “most combat-ready ship in the Pacific fleet.” (p.30).

  • “I found that the more control I gave up, the more command I got.” (p.6).

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BC10) How Dr. Peter Pronovost saved 1,500+ lives... with a checklist

 

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BC11) How UPS dramatically reduced serious crashes... and saves $300 million per year

"...turning left is one of the leading “critical pre-crash events” (an event that made a collision inevitable), occurring in 22.2 percent of crashes, as opposed to 1.2 percent for right turns. About 61 percent of crashes that occur while turning or crossing an intersection involve left turns, as opposed to just 3.1 percent involving right turns."

"UPS, which makes 18 million deliveries a day in the US, says that Orion analyzes 250 million address points a day and performs 30,000 route optimizations per minute. This saves the company $300 to $400 million annually in fuel, wages and vehicle running costs."

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BC12) "Doctors Say ‘I’m Sorry’ Before ‘See You in Court’"

by Kevin Sack in the NY Times

"The number of malpractice filings against the University of Illinois has dropped by half since it started its program just over two years ago, said Dr. Timothy B. McDonald, the hospital’s chief safety and risk officer. In the 37 cases where the hospital acknowledged a preventable error and apologized, only one patient has filed suit...

 

...34 states have enacted laws making apologies for medical errors inadmissible in court, said Doug Wojcieszak, founder of The Sorry Works! Coalition, a group that advocates for disclosure. Four states have gone further and protected admissions of culpability. Seven require that patients be notified of serious unanticipated outcomes."

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BC13) Case Study | Embedding a System to Protect Patient Safety

by the Virginia Mason Institute, April 21, 2018

"from May 2005 to May 2015, professional liability claims saw a 74% reduction, resulting in considerable savings each year."

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BC14) From Safety-I to Safety-II: A White Paper

by Erik Hollnagel

"Safety management should therefore move from ensuring that 'as few things as possible go wrong' to ensuring that 'as many things as possible go right'. We call this perspective Safety II."

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BC15) Virginia Mason's Clinical Transformation: Hard Work, Big Payoff
by Jeff C. Goldsmith February 7, 2011

"It required VM [Virginia Mason Health System] and its workforce to fundamentally rethink and renovate long established workflows, habits and routines. But most significantly, it involved redistributing power away from VM’s “owners”, the physicians, and enabling even the most junior nurse or aide on a patient unit to “stop the production line” by calling a Patient Safety Alert, triggering an immediate collaborative analysis and correction of defects."

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BC16) Can Patient Safety Incident Reports Be Used to Compare Hospital Safety? Results from a Quantitative Analysis of the English National Reporting and Learning System Data
by Ann-Marie Howell et al., 9 Dec 2015

"The NRLS [National Reporting and Learning System] is the largest patient safety reporting system in the world.... The study did show that hospitals where staff reported more incidents had reduced litigation claims..."

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BC17) Promoting Patient Safety Through Reducing Medical Error: A Paradigm of Cooperation between Patient, Physician, and Attorney
by Brian Liang, 1 Sept 2000

"Patient safety has recently become a predominant health law and policy issue. It has been recognized that the vast majority of patient injury occurs due to medical error, and that systems analysis and lessons from other highly complex systems may be useful to reduce error and improve safety. Current medical efforts, however, focus upon individualistic "shame and blame" methods; such punitive approaches are antithetical to well-recognized systems that effectively reduce injury."

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BC18) 10 lessons for speaking-up: learning from Virginia Mason’s PSA system
By Aled Jones, December 13th, 2018

"The Patient Safety Alert (PSA) system was introduced in 2002 following a staff survey. This showed that staff were fearful of speaking-up about concerns. Also, staff doubted that information generated from concerns would improve the safety of care. At the time of the survey VM staff wishing to raise concerns had to complete a quality incident report (QIR). Typically, QIRs would sit on a shelf collecting dust for months, then filed away and forgotten."

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BC19) Black Box Thinking: Why Most People Never Learn from their Mistakes, but Some Do

by Matthew Syed

A great introduction to the applied psychology of human error. No jargon. No unnecessary academic terminology. Just powerful stories of real world errors and evidence-based ideas for how to manage them better.

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BC20) Respect, Trust, Partnering and Safety...Excellence Emerges...and it Matters! by Richard Knowles

"Trust was built, people opened up, shared their ideas, learned, made decisions about improving their work, and brought occupational safety, health, and process safety management together into an integrate whole. The mood of the entire organization became very positive as things came together. In just four years the people had cut our injury rate by 97% to a Total Recordable Injury Rate of 0.3, reduced our emissions to the air, water, and land by 95%, improved productivity by 45% and increased earnings 300%."

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BC21) The Swedish Trucking Safety Improvement Project in "Managing Maintenance Error: A Practical Guide" by James Reason (pp.107-109).

"The Swedish study using this technique has two very interesting findings. First, the 850 drivers involved in the discussion groups showed s 50% reduction in driving accidents... The second interesting finding was that most of the drivers involved in the discussion groups did not believe that these activities had played any significant part in this reduction (although the results outlined above clearly show that they had)."

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