By far and away, the most common breakdowns occur due to the other four items mentioned. Therefore, when a lab value ordered on a patient in the O.R. does not return in a timely fashion, it is most likely due to non-people problems. Examples would be a slow elevator for the transporter, no notification that it was a stat order, slow function of the lab machine conducting the test, a lack of appropriate solvents to run the test, etc. This concept of processes gone awry as a cause of inefficiencies and errors in the practice of medicine are critical in our efforts to improve medical care. The field of quality assurance has relied upon the measurement of quality indicators in order to ascertain whether adequate performance is being met.
Examples abound in both industry and medicine.
A certain percentage of defective parts in a manufacturing process may occur. The percentage of defective products in a given unit of time can be set as a standard and when this standard is not met, then corrective action can be taken. Similarly, a nosocomial infection rate to two percent is a generally accepted level. If a particular hospital exceeds this rate, a study of possible causes would be in order. Cesarean section rates, unexpected transfer to the ICU, and readmissions to a hospital within 14 days for the same diagnosis are also examples of quality indicators.