Preventable Human Error, CDC, Health and Health Care: Why Fail Safe is Impossible and Transparency is Essential
This is a story of preventable error at CDC and the agency response. I hope it points the way to the real time QIPI & B2 health and health care outcome tracking systems we advocate.
On June 19, 2014 the New York Times posted this story of human error discovered at the CDC
C.D.C. Details Anthrax Scare for Scientists at Facilities
Below is my email response to the CDC.
July 14, 2014
Ladies and Gentlemen:
This will become a topic of conversation and an open letter to the CDC on my blog @www.VeritasHC.org.
Thank you for the transparency and truth. We can all learn from the CDC Lab fiasco and, in the process, CDC can put a model on display for the larger picture of Quality and Performance Improvement in Health and Health Care. As with the VA, this CDC failure represents the tip of the iceberg that reflects the larger issue that plagues all Health and Health Care institutions … preventable bad outcomes. Human Failure is inevitable and mistakes will be made, but they can be minimized with proper attention to details … all details of the problem, how it occurred and why … with remediation … and redesign. You folks know this … it is the fabric of the science that is the backbone of the CDC … an institution that has been my “go to” reputable organizational foundation for more than 40 years.
You also know that “Fail Safe” is not achievable in human systems, but it is the only proper target in Health and Health Care. In other words, we know there is no room to cut corners on care if we are to do what we are charged to do as care givers. Regrettably, although we know that best quality is the best cost containment strategy, we know it is not the common practice and things are not improving.
As a guy who has done Quality and Performance Improvement in Health and Health Care for the last 40 years, I have seen a decline in care and quality associated with the push for profit over people forced upon providers by the third parties in the “Business of Medicine”. Because front line providers are forced by managers and leaders to diverge from practices that are sound and fundamental to good medical and nursing care, the care quality and outcome gets worse … and worse … as time goes on. Yes, it is obvious. I see it every day in my clinical work … in the ICU I see the failures of our Health and Health Care system … that result from sloppy care and cutting corners to “save money” … to what end? More profits for the fat cats and profiteers? Is this what is happening to science at CDC? Cut corners, sloppy practices and bad science to “save money”?
The decline in US Health and Health Care is obvious … intuitively obvious and obvious to the world in our rankings. And now, I am forced to “prove” these things to the “leaders” who have no sensitivity to things that are human and for which there are no metrics. In other words, there are no sensors or metrics for individualized and personalized needs apparent to care givers … those things that are not a part of the product lines designed to fit each disease … in ALL patients … regardless of their personal needs. What is this madness? The same assembly line practice for each “disease” … for one and all patients? Designed by people who have no clue about caregiving and what it takes to deliver quality patient care? Nor do they care … why not? There is more profit in bad outcome … not just my opinion, but a documented fact.
Health and Health Care is much like growing people or raising children. Individualized and personalized care works and when we give patients what they need when they need it, they will get better … just enough and at the right time … the right things at the right time in the right location and, if it is meant to be … even the sickest get better. None of this has changed … but the accidents of space and time that are now the US Business of Medicine have changed … in that most fall through the cracks.
The latest business and government fashion is to squeeze more work out of fewer people and to disregard human constraints and limitations. The focus on numbers and disregard of the human factors is palpable as are the increasing failures as more technology is added to the loop … increasing tasks … meaningless tasks to the essential scientific procedures. These tasks are distractors and detractors from the mission which is medical, or, fundamentally, scientific. So, the administrative solutions fail … over and over … in fact, they simply make things worse.
I am impressed by the transparency you folks have put on display with regard to the recent CDC Lab errors and would like to know more about the details of the case. In particular, was this goof a result of erroneous cost containment strategies? Is this a reflection of leadership that is insensitive to the human needs of the CDC workers on the front lines? Are you instituting “efficiency” practices to “cut costs” that result in increasing production pressure and bad science? I suspect this is the case. If so, we all need to know.
I trust that CDC will take a proper dose of medicine to rid itself of disease and resume activity as a model of great science.
This is the email response I received today, July 28, 2014
Dear Dr. Mascia:
Thank you for your message sharing your concern about the recent laboratory incidents at the Centers for Disease Control and Prevention (CDC). We appreciate that you recognize our efforts to maintain transparency in the wake of these events and value your perspective and expertise as a health care professional.
To adequately answer your questions regarding why the incidents happened, I invite you to watch CDC Director Dr. Thomas Frieden’s testimony about this issue before Congress. A recording of the hearing can be accessed at www.c-span.org/video/?320417-1/hearing-cdc-anthrax-lab-incident.
In addition, CDC released an official review, Report on the Potential Exposure to Anthrax, that includes details of the anthrax incident and CDC’s response. It also discusses the agency’s plans in the case of similar events in the future. The report is publically available and may be accessed at www.cdc.gov/od/science/integrity/docs/Final_Anthrax_Report.pdf.
Thank you again for your message and for supporting CDC. We hope the information provided in Dr. Frieden’s testimony and in the report is helpful to you.
Pamela J. Cox, PhD, MA
Director, Executive Secretariat
Office of the Chief of Staff