Here's How Writing A Book Prevents Errors In Healthcare

By now you probably know: healthcare errors happen when weaknesses in a system align.

You may call it "holes in the Swiss cheese" or "holes in lines of traffic" like in that classic game Frogger.

But whatever you call them, the 6M's of errors (Man, Materials, Machine, Method, Mother-nature, Management / Measurement) are starting to take hold as well-known classics in the field of "why things go wrong" in Healthcare.

Sometimes, staff call these classics the 5M's and 1P--they replace "Man" (generic for "humans") with "People" because some argue the memory tool sounds better when there's no gender-specific term.

Whichever word a group uses, let me tell you: some of the holes in a system are harder to shore up than others.

Want to know one of the most difficult ones? People. Yup...but probably not in the way you think. Let me tell you more...

Some quality improvement systems in healthcare fall down because they focus on the people involved in a quality issue to the exclusion of all else.

In other words, some process improvement systems give the illusion that a people issue is behind every problem they're seeing in their system. That's just usually NOT the case. (I've written about that previously here.)

But sometimes people do play a role. And when they do...adjusting things can be tough. That's where a book can really help.

Of the many different things that can hurt a system on the people side, one of the worst is a knowledge base deficiency. After all,

The eyes can't see what the mind doesn't know. --Attributed to many authors

There have been MANY turns on this phase (perhaps most famously by DH Lawrence)--but the line of thinking is typically the same. If the mind is unprepared for something, or if there's a framing bias or knowledge deficit, well, then what?

The "then what" part is often medical error and patient injury. So what to do about it? Again, this is where a book can really help.

The creation of one common body of knowledge, specifically one for a particular group, can help spread the important, shared mental model. It may help those of us who work in a system "see" better.

Sometimes, that book can be a shared body of facts to help trainees prepare for important tests and provide patient care.

For example, I recently completed one such book, ABSITE Smackdown!, and the publisher posted it here.

That work is targeted to improve the knowledge base of trainee colleagues, to build knowledge into how we provide care at our center, and to allow it all to happen in a comfortable, non-confrontational way for staff.

It targets some of the important facts we may not realize until we're educated and our minds are "prepared" to help our eyes see. It's all done to reduce medical error and provide better care.

And what have we seen so far? We've seen staff begin to build a shared body of knowledge, to explore the facts contained in the work, and to watch the included video lecture series as they begin to see the medical world differently together.

And it's not just surgery residents...ER resident colleagues, Family Practice resident colleagues, and learners from around the country are spending time with the work and getting prepared to see certain conditions they may never have seen before.

Writing a book can definitely help shore up the Man (or People!) portion of your system by creating that shared knowledge base and preparing the mind to see.

Dr. David Kashmer is a quality improvement expert, & trauma and acute-care surgeon. He earned his Medical Doctor degree from MCP Hahnemann University--now Drexel University College of Medicine--and his Bachelor of Science degree in biology from Villanova University through a joint BS-MD program with MCP Hahnemann. He has previously served as a Section chief, Chief of Surgery, & Chief Medical Officer for healthcare organizations.

He recently authored ABSITE Smackdown!, an ABSITE review book with video lecture course included. (Available here and on Amazon.)

David also earned a Lean Six Sigma master black belt certificate at Villanova. Dr. Kashmer holds a Master of Business Administration degree in Healthcare Administration from George Washington University. He previously served on the Board of Examiners for the Malcolm Baldrige National Quality Award and now focuses on educating resident colleagues.