Attack the problem, not the people

Back in May, I wrote about an error regarding a kidney transplant at UPMC, where a surgeon was demoted and a nurse was suspended. I wrote, "Guessing from a press report, I am betting that this story is not totally a person problem," suggesting instead that there were systemic problems at UPMC that underlay the error.

Now, the Pittsburgh Post-Gazette offers support for this view. Sean Hamill reports:

The positive hepatitis C test that was missed at UPMC, leading to the shutdown of its living donor kidney transplant program, was not noticed by its entire transplant team despite a highlighted alert in the hospital's electronic records system.

"Everyone just missed it," a source with knowledge of the case said.

The alert was missed by as many as a half dozen people on the transplant team who typically would have reviewed such a test result, according to interviews with several current or former UPMC employees. A number of those interviewed said the problem lies more with the larger system of ensuring that medical errors are caught than with the individuals involved in the incident.

Here's my unsolicited advice to people at UPMC: Attack the problem, not the people.