Improvement Insights Blog

10-15 people out of 100 are misdiagnosed leading to waste, rework and patient harm. It’s a mistake to say “To Err is Human.” Blame the System, not the person. Here’s why:

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“Hi, I’m Jay Arthur, author of “Lean Six Sigma For Hospitals” and QI Macros [software].

“I was recently at the Institute for Healthcare Improvement conference, and I went to a session where they talked about diagnostic error. It turns out that 10 to 15 people out of every hundred are misdiagnosed, which means they are treated with the wrong stuff and they don’t get better and they might have other complications from the treatment. Right? This is where some of the costs come from in the estimated trillion dollars in waste and rework in healthcare.

“I was listening to this, I was thinking back… I think, back in about 2005, I read a Business Week article that said 10 to 15 people out of a 100 are misdiagnosed. Well, that means it hadn’t changed in a decade or two. What? And as I was listening, people were talking about… The problem is, nobody wants to be blamed for this mistake.

“Now, I want you to hear my point of view on this: Blame the system, not the person. Systems let people make mistakes… systems let people make mistakes. Right? Don’t blame the person. The system made them do it.

“As soon as you decide to shift your attention from people to systems to processes, all of a sudden you can start to make real progress about things. But as long as you blame people, you [think] “To err is human.”

“You know… They have these “M&M” meetings: morbidity and mortality. They look at why people were permanently injured or killed due to a medical mistake, and they kind of keep it under wraps. But no, don’t blame that person. Blame the system that lets them do that.

“So that’s my Improvement Insight: Shift your attention; blame the system.

“Let’s go out and improve something this week.”