Implementing Technology- It Doesn’t Always Lead to an Improvement

We are very fortunate in the 21st century to benefit from various technological advancements. Computers and microchip technology have made so many things much easier. Being able to order things online or obtain information on your smartphone is a huge improvement over driving to the shopping mall or searching through a dated encyclopedia.

But technology implementation by itself frequently does not make things better and sometimes can make it worse. In a sad aviation disaster, American Airlines Flight 965 was a regularly scheduled flight from Miami International Airport in Miami, Florida, to Alfonso Bonilla Aragón International Airport in Cali, Colombia. On December 20, 1995, the Boeing 757-200 flying this route crashed into a mountain in Buga, Colombia, killing 151 of the 155 passengers and all eight crew members. The flight management system in the 757 is capable of flying the plane by itself. It follows the flight plan that is entered before the plane takes off. In the case of flight 965, the pilot and co-pilot decided to change the landing to a different runway and approach and essentially disabled the flight management computer.

Recently, a family member was on a trip from Boston to Bermuda. She was waiting for her JetBlue plane to board when she received an email that her bag had been put on the plane. She was shocked, however, to read in the email that her bag was on a plane bound for Nashville.  A hole in the Swiss cheese, in the James Reason error model was the similarity in the airport identifying letters – Bermuda (BDA) and Nashville (BNA). A baggage handler must have “seen” BNA when my family member’s bag tag was clearly marked BDA. JetBlue, evidently in trying to reduce the frequency of lost baggage had implemented a bar code or rfid scanning system such that the bags were scanned before being put in the baggage hold. However, it is likely that when my family member’s bag was going into the cargo hold of the plane bound for Nashville that a light flashed “red” to alert the baggage handlers that the luggage didn’t belong on that plane. But no human took action to get the bag on the correct plane, the one bound for Bermuda.

My family member reported her bag lost to the JetBlue staff in Bermuda. They created a lost baggage claim in their system and my loved one then got an email telling her how to use the on-line portal to follow her bag’s path from Nashville to Bermuda. She checked the portal frequently over the next 28 hours, but the system only said, “no information.”  Again, expensive technology that was not being used properly and therefore of zero value to the traveler. This is the definition of pure waste. 

So, the moral of the story for us in healthcare is that technology by itself does not eliminate errors. It just moves the error to the so-called man-machine interface.  When we implement technology, we must enroll the people who will use the system in the reason why we are implementing the technology. Then we must engage them in creating their standard work in the use of the system and lastly, we must assure ourselves that the standard work is being followed. Otherwise, we will get no benefit from the technology and we might actually make things worse.

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