Yesterday I had the opportunity to give a presentation at
the National Society for Histotechnologists at their Annual Meeting in
Vancouver. This was the second time that
NSH as met in Canada. This was a good
time to have a meeting in Vancouver. I
don’t know what is and what is not a manifestation of climate change, but this
has been one magnificent late summer and fall in British Columbia.
The meeting had by my estimate maybe 700 attendees (?)
with a nice group attending my presentation on Costs of Poor Quality with a
focus on TEEM impact factors. If you
have visited here before, TEEM describes the impacts and consequences of error
in terms of Time, Effort, Energy and Money, where
effort describes physical strain and Energy describes mental stress.
This was my first oral presentation on the concept of
TEEM impact on Quality. It describes the
impacts of Effort and Energy on medical laboratory error.
I started with the argument that most laboratory errors
are the result of slips and distractions, and sometimes poor judgements. But these don’t just happen in a vacuum. Sometimes, stressing and straining systems
factors like noise and crowding and workflow increase the likelihood of
error.
In addition, I drew on the literature from laboratory
safety. An old and small but very
insightful study by G. Briggs Phillips on the human factors associated with
laboratory accidents [ see: Laboratory Safety: Principles and Practices, published
by ASM Press in 1986] pointed out that attitude and situation impact the risk of error and accidents
significantly.
My central point was that underlying factors that cause
stress and strain can increase the likelihood of error that gets described as a
human foible or slip, but slips often increase the level of stress and strain
which in turn increases the risk of error. What I have added is some scales that can (once
validated) be used as measures of stress and strain, that the astute manager
will be able to apply as an indicator of rising risk for error.
Brilliant?; no.
Inventive?; no. But I think it
has the potential of being a good example of an innovative tool for Quality and
Risk managers.
I promised the attendees of the conference that I would
post the presentation on-line in lieu of giving a handout. (I hate giving handouts. They are expensive, and always distracting,
and usually end up in the proverbial round file.)
For those interested, you can see the presentation at: http://www.polqm.ca/pdf/NSH2012%20-%20Counting%20the%20Costs_F.pdf
Invite comments.
Note:
I have re-activated my
Twitter ® account. @Qualitology for a number of
reasons which I will explain later.
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