October 4th, 2014

woods, Elizabeth, camera, April

Failure Analysis and Ebola

When I was a child and knocked a glass off the table, my mother the engineer led me through one of my first failure analyses:  a consideration of why and how the glass ended up on the floor along with the milk in it, a model of how, as she said, "Accidents don't happen: they're caused."   Not always by a human (though usually) and certainly not always by the person who's hurt.  A friend of mine was killed by a tire that came off a large truck going the other way, into oncoming traffic, where it smashed into the windshield of her car and crushed her face into her brain.   Her teenage daughter, a front-seat passenger, grabbed the steering wheel and steered the car safely to the side of the road.  That was certainly not Sally's fault.   But in any situation, my mother's response was to analyse what went wrong so that a similar unwanted event would not happen again.   I had set the glass of milk on the edge of the table (easier for me)  where it could easily be knocked off the table.  I remember, in that and other occasions when I was led through the process of analysis, resenting it.   It was an accident...I hadn't meant the glass or plate to fall, I hadn't intended to drop something breakable, I hadn't planned to flunk that test.   Those responses, so natural to a child and to many adults, met firm correction from my mother:  it wasn't about what I meant to do, what I planned to do, but what I actually did.   I learned---not as well as she wished--to think ahead at least two steps, to imagine alternate possibilities, to look for ways things might fail, rather than assume they would not.   I was encouraged to consider what to do if they did--to have a Plan B, and also a Plan C, D, E.  Did I always do it?  No.  Did life itself teach me why it was a good idea?  Yes.

Which leads us to the curious affair of the Dallas hospital letting an Ebola patient leave the hospital because they didn't realize he might have Ebola, even though he told them he had come from one of the countries known to be suffering an Ebola epidemic.   This is, in epidemiological terms, a big-F Failure.  How could a major hospital in a major US city that has a very large, international hub airport, make that mistake, a mistake with potentially deadly consequences? Collapse )
woods, Elizabeth, camera, April

One Failure Point--One Low-Tech Solution

So it seems that other hospitals in oither states using the same software have, potentially, the same problem that Texas Health Presbyterian Hospital found in its software: there is no way to put a big whopping flag on the intake chart to indicate a known serious risk.   Programmers are no doubt downing coffee and chocolate and trying to modify the software without crashing everybody's system (which would not be good.)

But there's a fast, cheap, effective way to deal with this, says the writer who lives on both sides of the high tech/low-tech divide.  (No dishwasher, no smartphone, but computers and high-speed internet.)

Bright-colored (I suggest yellow, the color of the traditional plague flag--bright, easily noticed if it falls to the floor, etc.)  3x5 cards easily obtained in any office supply store, plus a stamp that says "Priority", an indelible marker (probably already at the ER intake desk) .  

Step one:  Hospital prints out a sheet to be taped to the staff side of the intake desk.   It reminds staff to ask specifically about travel  or residence in Guinea, Sierra Leone, or Liberia within the past 21 days.  Staff doesn't have to remember which countries--it's right there in front of them.   At the foot of the sheet is the in-hospital number they're to call if they "card" someone.

Step two:  Upon getting a positive answer to the question,  staff person writes patient's name on one card and hands it to the patient, asking the patient to wait right there.  Staff person clips second card to clipboard; if patient used that clipboard to fill out information, use the same clipboard.. 

Step three: Staff person 1 calls the contact number that will immediately initiate response to possible Ebola patient.   Upon arrival of team to ER waiting area, staff person 1 hands off clipboard to nurse or doctor, followed by immediate handwashing while another staff person, gloved, swabs down everything the patient touched.

Advantages, besides cheap, fast, and simple:  no physical contact between patient and staff is required in the ER.  Contact with other parts of the hospital is minimized--transport to an isolation area is controlled by a trained team, who will have with them, both protective garments and containment for any bodily fluids that emerge between the ER and isolation.  ER staff beyond the admitting office are not contaminated and will not need even brief isolation (allowing the ER to continue to function) and anyone in the ER when the possible Ebola patient arrives can be identified immediately for follow-up.