Correcting Errors Early: Source checks, Self checks, and Successive Checks

The Lean Healthcare Exchange has an excellent article about source checks, self checks and successive checks. This concept needs to be incorporated into standard work procedures in healthcare whenever other error-proofing methods are not in place. And that would be most of the time.

The need for these checks stem from the fact that there is so much opportunity in healthcare to cause great harm from simple mistakes: fat fingering a medication order in the EMR, transposing two numbers in a lab result or medication dosage, or confusing left and right when performing a procedure on a patient. Smart people can easily make these kinds of mistakes. Source, self, and successive checks prevent these errors from harming the patient.

The classic example of this is the surgical time-out. The nurses, surgeon, and anesthesiologist stop what they are doing and review the procedure and location on the consent. This successive check ensures that they are doing what the patient and physician intend.

Unfortunately this assumes that everything leading up to the written consent is correct. The recent example of a surgeon removing the wrong kidney from a patient illustrates the problem with this. It turns out the wrong kidney was reported as cancerous in the medical record. Lets look at how source checks, self checks, and successive checks can help prevent this type of error.

• The radiologist performs a self-check to ensure the film is not backward before reading it.
• The radiologist reads the film again (source check) just prior to reporting the result.
• The physician double checks the radiology report before ordering the surgery (successive check)
• The physician looks at the film himself before ordering the surgery (source check)
• After ordering surgery the physician compares what he just ordered with the radiological report (self check)
• The surgical team checks the consent before starting surgery (successive check – this is standard practice, and is what the team did)
• The surgical team checks the original film before starting surgery (source check – this is the new procedure instituted at the hospital in question)

All of this checking and re-checking seems like wasted activity. But eliminating the defect early on is much less costly than letting the defect get to the customer. This is true in manufacturing, and it is even truer in healthcare.