Improvement Insights Blog
To Err is Human?
Some people think humans will always make mistakes and there’s nothing we can do about it. I disagree. Here’s why:
“Hi, I’m Jay Arthur, author of “Lean Six Sigma For Hospitals” and the QI Macros [software].
“Back in 1999, the Institute of Medicine published a book called ‘To Err is Human’ which showed that healthcare kills about a hundred thousand people a year unnecessarily. Since then, we’ve gotten better at measuring that, and it’s probably three to five times that much, give or take a few hundred thousand… But my thing about this was it presupposes that humans will make mistakes and that’s not preventable; not preventable.
“I believe that error is not… it’s not about humans, it’s about systems. ‘To err is systems… systematic.’ It’s your processes, it’s your information systems, it’s whatever you do: your paperwork, your policies, your whatever. It is entirely possible…
“I have this limiting belief: I believe it is entirely possible to mistake-proof everything, everything, so that nobody ever makes a mistake. You can’t. Your systems won’t let people fail. That’s what happens; people fail. In my car, I have to step on the brake to start the car. You can’t start the car unless you step on the brake. Well, duh, right?
“I believe it’s possible to mistake-proof everything. You know the little tongs on [the] electrical cords? One of them is fat so you can’t stick it in backwards… can’t do it.
“All right? So i want you to get this idea it is entirely possible. Share my delusion, my limiting belief that it is entirely possible to mistake-proof everything. The more you focus on that, the more you get to the point where things don’t error anymore. I worked very hard on that in the QI Macros, but every once in a while I still miss something that I haven’t thought of, and then I fix it so it’s mistake-proof now. I want you to get this idea it’s entirely possible to mistake-proof everything.
“That’s my Improvement Insight: Let’s go out and mistake-proof something this week.”
