I enjoy building LEGO projects with my grandchildren, because it is possible to sit with a grandchild for several uninterrupted hours, unlike video games or watching them scroll on cell phones. Our last project was a LEGO Technic set, which lets the child learn about engineering principles like cams, levers, and fulcrums. This project was estimated to take 7 to 8 hours to complete. We made the mistake of misplacing a piece by just one hole, and the additional pieces didn’t fit in the construction. As a result, this mistake took two hours to unravel and go backward to fix the problem. I hope that my grandchild learned persistence, perseverance, and that mistakes and errors are part of daily life.
The LEGO Technic metaphor has application to our health care practices. Small mistakes in health care can have disproportionately large consequences, because patient care is often a complex system where many processes depend on accuracy, attention to detail, and the importance of communication.
Examples of the necessity for attention to detail:
- Submitting a claim to an insurance company that has a single-digit mistake in the patient’s insurance ID or the birthdate of the patient will result in a claim denial and delayed reimbursement. A clean claim is possible.
- A physician intends to prescribe 0.5 mg of a medication but accidentally writes 5.0 mg. An error of a single decimal point, and the patient could receive ten times the intended dose, potentially resulting in severe side effects, hospitalization, or even death.
- A nurse administers treatment without confirming the patient’s identity using two identifiers. This error may result in the wrong patient receiving medication, blood products, or a procedure intended for someone else.
- A physician overlooks an abnormal laboratory result in their inbox. A diagnosis of cancer, sepsis, or another serious condition may be delayed, allowing the disease to progress.
- A physician fails to mention a patient’s allergy or a drug-drug interaction during a shift change. The next provider prescribes a medication that triggers a severe allergic reaction or a drug-drug interaction.
- Information copied and pasted into the electronic health record is not updated. This creates the potential for incorrect diagnoses, medications, or treatment plans that impact or influence future clinical decisions.
- A staff member forgets to contact a patient regarding a suspicious imaging finding. This may result in a potentially curable cancer being diagnosed months later at a more advanced stage.
- When a biopsy specimen is mislabeled, one patient may receive a cancer diagnosis they do not have, while another patient with cancer goes untreated.
- A physician recommends that a patient take a medication “twice daily” without clarifying the timing of the day that the medication is to be used. If this is unclear to the patient, the patient may take both doses together, reducing effectiveness or increasing the side effects.
- If a doctor or a staff member skips hand-washing hygiene between patients, a nosocomial infection may spread to multiple patients.
- A staff member might dismiss a recurring alarm on a monitoring device in the ICU. Warning overload is a significant problem that has the potential to mask a true emergency, delaying recognition of a patient’s deterioration.
These 11 examples illustrate a health care version of the “butterfly effect”: a seemingly insignificant action can trigger a cascade of events leading to major outcomes. Often, catastrophic events are not caused by a single large error but by a series of small mistakes that align at the wrong moment.
My take-home message is this. Small actions rarely stay small. A missed checkbox, an unchecked allergy, or an unreturned phone call can become an emergency. Excellence requires getting the little things right.
In my practice, I have a large sign posted so that the staff and patients can easily see that it states, “We believe in the little details because they make a big difference.” This concept works particularly well for physician practices because it emphasizes the importance of attention to detail by every member of the team, from the front desk to the physicians. So let my LEGO Technic experience be a lesson that it is important to do it right the first time, to avoid making costly mistakes that can impact our patients’ safety and health.
Neil Baum is a urologist.
