A couple of weeks ago, a very popular restaurant in the Bay Area initially caused over 80 people to become very ill from food they ate at the restaurant. Over half were hospitalized and a dozen required intensive care. Worse than that, the type of bacteria, Shigella, spread from the initial wave of infected people to secondary infections of another 120. Clearly, this is one of the worst things that can happen to a restaurant’s reputation as it was widely reported on the news to warn people who patronized the restaurant as well as people who prepared or shared food with an ill person.
Shigella is spread by an infected person who has direct contact with food or drink that is consumed. Washing hands for 20 seconds with soap and water is recommended by public health officials as a preventive measure. It is a requirement for food workers to wash their hands before handling food. Washing hands is a best practice for many jobs that where workers come into direct contact with people or food. In this case, the best practice failed.
There are many stories of patients who have had the wrong limb removed in surgery or an incorrect procedure performed. Hospitals have implemented procedures to avoid these kind of life-altering errors, but if you are the patient, do you trust that their procedures and processes work? If they don’t work, the patient is the one who suffers. So in spite of that, patients can and do put their own backups in place–they write on their arms or legs to indicate that it is the wrong side or family members can confirm with medical personnel involved in a procedure exactly what procedure is being performed on their relative. One time, when my father was in the hospital, his room mate was a patient with almost the same name–there was only one letter different in the surname of four letters. Not only did they visually look alike, the two names sounded alike–Chan and Chen. I was concerned that my father would receive the wrong medication. Each time he received medication I had my mother tell the medical staff his name and made sure they agreed that he was the correct person, not the room mate. That was not a sure thing, but at least the staff was aware that we were trying to avoid any accidents.
Best practices are not fail-proof; they should have backups or redundancy built-in in case of failure depending upon the impact of a negative outcome. The bigger the impact of a failed procedure or process, the more backups or contingencies should be in place. Has your organization made a list of the most important procedures, the best practices, and the backups? Has an assessment been made of how well the best practices are working? Performing best practices 100 percent of the time is what makes them best.