Michael Dowling is Northwell Health’s President and CEO and the Institute for Healthcare Improvement (IHI) Board Chair. In a new book, Leading through a pandemic: The inside story of humanity, innovation, and lessons learned during the COVID-19 crisis, Dowling describes how Northwell’s history of disaster preparedness was essential to their COVID-19 response.
In the following interview with IHI, Dowling shares some sometimes surprising insights from an early epicenter of the pandemic.
Although the drawers in this filing cabinet are labelled there is no standardisation to it. How easy is to find the drawer you want if you are in a hurry?
Untidy filing. Documents not always put away. Paper falling out of cabinet. This can makes finding documents slow and time consuming and open to error if a document is put in the wrong drawer or lost.
These fluids stored here are all different. Although labelled, how easy is it to pick up the wrong one? Look at the red labels - is the label for the tray above or below?
The trap here is that the fluids stored here are all different. There is a normal saline stored next to potassium and glucose. In a hurry, the wrong fluid may be picked up and cause patient harm or even death.
Lisinopril tablets. Spot the pack with different dose. Very similar colours (purple and dark blue) to distinguish between 10mg and 20mg. Easy to pick up wrong pack if in a hurry.
One drug is a strong pain killer used in anaesthetics (Fentanyl). The other is also used in anaesthetics and is a paralysing agent (Suxamethonium). Both look the same, same dose. Very dangerous if the wrong one is given to patient.
Same packaging and text. Why isn't the dose in a different colour so it easily stands out? Busy staff have to look very closely at the boxes to identify the difference. Mistakes could easily be made.
They look identical but different drugs. Often stored in the same place. Not catastrophic for most patients if they were given by mistake but would be for patients who were allergic.