“We’re sorry…” CEO Toronto Hospital for Sick Children
Terrible story, folks, out of the Hospital for Sick Children. Sick Kids apologizes for drug-test failings.
Flaws in the Motherisk laboratory’s hair-strand drug and alcohol testing process might have caused some parents to lose custody of their children. Other parents might face unjust criminal convictions.
Children’s Aid Societies use the results of such tests to make decisions on custody and so on. After months of denial and deflection, the hospital has finally accepted responsibility and apologized.
Cold comfort to the victims, though. How many lives have been damaged?
As always, there are learning points. What are possible causes of this laboratory disasters?
- Poor overall layouts result in chaotic work pathways, which increase contamination risk
- Work Area Layout – are all the items technicians needs to do their work within easy reach, or do they have hunt and peck?
5S & Visual Management
- Are reagents, equipment, slides and the rest easy to find? Is it easy to tell, ‘what is it?’, ‘where is it?’ and ‘how many?’
All of these increase contamination risk.
- Are there simple, visual standards for the lab’s core ‘recipes’?
- Are standards checked and updated regularly, and ‘owned’ by team members?
Team Member Training Process?
- Are lab team members trained in core standards using robust methods (e.g. TWI)?
- Are team members cross-trained to build capability and ensure requisite skills are in abundance
- Does the hospital’s management system include daily stand up meetings in front of team boards wherein team members are encouraged to make problems visible?
Team Member Involvement and Problem Solving?
- Are team members trained in fundamentals like standardized work, visual management, and problem solving?
- Do leaders at all levels actively support total involvement and daily problem solving?
- Does the Human Resources system support and promote such leaders?
Hard questions, all.
My heart goes out to the victims.