Tuesday, December 09, 2014

A just culture at work

The health care world is abuzz with a report from Oregon about a woman who died from a drug administration error.  There are many details about what went wrong and why, but I was extremely pleased to see this statement from the hospital:

"While human mistakes were made in this case, we as a health system are responsible for ensuring the safety of our patients," the health system said in a statement. "No single caregiver is responsible for Loretta Macpherson's death. All of us in the St. Charles family feel a sense of responsibility and deep remorse."

Saddened, they also went right to work to fix underlying problems:

The health system said in a statement that it has put several measures in place to make sure the mistakes aren't repeated. It's enforcing a "safety zone" in its pharmacies so workers can complete medication verifications with fewer distractions, and it's bringing in an external pharmacy expert to provide recommendations.

The hospital system is also looking at changes in how patients are monitored after medication is administered.

Although newsworthy, this event is not unusual. There are many such errors that occur in hospitals, all too frequently.  Also, there are many times more that number of near misses that go unreported, each one of which offers the potential to uncover and remediate systemic problems.

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