The IOM Report - To Err is Human and The Center for Error Management


The following is a comparison of the recommendations stated in the Institute of Medicine’s (IOM) report entitled “To Err Is Human: Building a Safer Health System” and the premises of training by The Center for Error Management (CEM)

In the Executive Summary, the IOM’s report cites the death of Ms. Betsy Lehman, due to a drug overdose during chemotherapy as a major medical incident. This particular case is one of the examples of error addressed by CEM. It is discussed while introducing one of six human traps and tool kits called Group Dynamics Management. Specifically, within this tool kit Betsy suffered from a trap called “Co-worker syndrome”. It was discovered that not less than 12 individuals were involved in the administration of Ms. Lehman’s overdose; all expecting the others had made sure the dosage was correct. The report alludes to other accidents, which it calls “adverse events” and cites many figures and percentages to make the point that change is needed, to which CEM agrees.

Throughout the report, IOM refers to training, simulation, and safety practices that have been instituted by the military and commercial aviation industry. The report suggests the medical field should learn from these aviation practices and institute similar efforts. CEM’s thesis of error management is born out of these same aviation disciplines utilizing aviation case studies to establish training points.

The IOM report defines an error as “…the failure of a planned action to be completed as intended (error of execution) or the use of a wrong plan to achieve an aim (error in planning)”. The Center for Error Management addresses these errors as being a part of everyday life. To understand human error you have to understand humans are always present. They are at the planning stage, execution stage, monitoring stage and finale stage of every action. The human constantly is in need of evaluating each stage they are in and be ready to make changes. The IOM report called it being ready to “expect the unexpected”. This is what CEM prepares students to do.

The report discusses many facets of error concerns. It gives a historical perspective of errors, breaking them down into categories of equipment failures, medication application mistakes, patient safety concerns, congressional responsibilities and ultimately why all these errors happen. It also addresses the need for better reporting of errors by the medical industry and how this will provide for better patient care. Only through the comparison to the aviation industry does it address a proactive approach: the action of being ready and able to foresee possible dangerous situations or accidents in the making. This is the goal of The Center for Error Management’s training program. It is a phenomenon CEM entitles the “Error Chain”. A chain of events that must be recognized and broken before the accident, incident or error is made.

Specifically, chapter eight of the report entitled, Creating Safety Systems in Health Care Organizations recommends “…incorporating proven methods of managing work teams as exemplified in aviation”. The chapter establishes five specific principles which health care organizations are suggested to meet. Each of the principles is followed by a CEM tool, which can meet the expected criteria. The principles are:

Principle 1: Provide Leadership.
CEM trains students how to be leaders. To assist the Leader, CEM has created a “Make it Happen” Workshop that will introduce Tools forcing teams to address questions needed to be effective. This workshop will introduce Tools for the team to use that will keep situational decision makers apprised of all necessary data to make sound decisions.

Principle 2: Respect Human Limits in Process Design.
Through the training process, students will understand human limitations by periodically reviewing the Traps and Tools introduced by the six tool kits. Process designers will appreciate the individuals using the process and constantly evaluate the effectiveness of the process. Latent errors will therefore be mitigated through constant process review and awareness.

Principle 3: Promote Effective Team Functioning.
Students learn how teams become a single unit and the importance of their individual part of the team. An additional tool called TEBS will promote each of the team members and allow effective communication within the team. Authority for all to participate equally will be addressed. Each will discuss the Task, Equipment, Barriers, personal Skills needed to complete a mission as it is intended.

Principle 4: Expect the Unexpected.
Tools will be introduced allowing team members to monitor the process throughout any task application. When “unexpected” events occur the “expected action” will take place through use of a tool called QPIDR. The event will be Questioned. The Promotion of Ideas will take place. A Decision will be made. The event will then be monitored through a Review process until completion.

Principle 5: Create a Learning Environment.
The training process is designed to be a continuous review of The Center for Error Management’s premise of error management. It will surface needed changes in standard operating procedures; it will identify equipment anomalies; it will identify the required skill level of each person on the team; it will make sure the team is capable and ready to complete the task as intended. Tools will also be available to assist in the implementation of an error management culture.

The Center for Error Management is quite different from other human factor efforts in that humans are recognized as the creator of systems, processes, and machines. Only humans can evaluate the readiness and correctness of each. CEM also understands that psychological, emotional, and physiological factors affect human readiness. It is those factors students need to accept and be able to counteract. In short, CEM desires to make all individuals and teams accountable, responsible and effective.

- Larry Foss

© The Center for Error Management 2004-2011