Over the course of two days, a U.S. airline placed an unaccompanied minor on the wrong flight on two different occasions. On June 13th, a child flying alone and under the supervision of the airline was scheduled to fly from Houston to Charlotte. Instead, she ended up in Fayetteville. One day later, a second occurrence with the same airline, this time out of Boston. Instead of going to Cleveland, this unaccompanied girl ended up in Newark, NJ. (See the news report.)In response to the reason for the mix-up, the airline said that in both cases two flights were departing simultaneously from a single doorway and miscommunication among staff resulted in the children being placed on the wrong plane. The solution given was “Reinforce our procedures with our employees.” I decided to build a Cause Map (visual root cause analysis) for this incident since it serves as a classic example of an error we typically see during an investigation… stopping short. In fact, an airline spokesperson had even stated:
“We fly thousands of unaccompanied minors every year and the procedures work when followed.”
Fortunately, neither girl was ever hurt and eventually made it to their final destinations, albeit delayed and a little frightened. No real harm done, so what’s the big deal? As long as we follow the procedures going forward everything should work out just fine.
Now imagine we replaced the word “unaccompanied minor” with “patient” and the word “wrong plane” with “wrong medication” and you immediately change the stakes. A 1999 report issued by the Institute of Medicine (IOM) estimated that between 44,000-98,000 patients die each year as a result of medical errors. Now let’s look at the above again in a different context…
“We perform hundreds of millions of medical procedures every year and the procedures work when followed.”
Doesn’t sound like a very good excuse anymore. The point is that a procedure is simply a series of steps to produce an end result. If we don’t get the outcome expected then the procedure is not effective, even if it works 99% of the time. To improve your processes you must break it down into specific steps and then it is much easier to pinpoint what didn’t go well. At this point in the root cause analysis, you can now dive into the cause-and-effect relationships. To see an example applied the plane incident described above check out the case study and PDF.
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