tag:blogger.com,1999:blog-32053362.post1790711885229043349..comments2024-03-26T00:25:34.026-04:00Comments on Not Running a Hospital: Leaders fail: The blame game continuesPaul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.comBlogger9125tag:blogger.com,1999:blog-32053362.post-10353421198696436852013-11-28T01:35:41.230-05:002013-11-28T01:35:41.230-05:00Very well said. I also work in a hospital and I th...Very well said. I also work in a hospital and I think that the number 1 contributing factor to errors and near misses is the hospital policy itself. If the management will have a clear sense of responsibility and accountability, like Mr. Wiles, errors will be prevented.Joannalynehttps://www.blogger.com/profile/12235256835014466828noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-22945939847434762202012-09-29T09:50:16.140-04:002012-09-29T09:50:16.140-04:00In reading the article below from the Soccer Ameri...In reading the article below from the Soccer America Daily blog, I am reminded of the many times you note a martyr of transparency that helps make the next step in improvement possible. Thanks again, <br /><br />Ref who missed England goal favors GLT<br />AP<br /><br />Jorge Larrionda, the referee who failed to see a shot by England's Frank Lampard cross the goal line at the 2010 World Cup, says he's in favor of using goal-line technology (GLT) to aid match officials. Uruguayan official was running the middle during England's 4-1 loss to Germany in the first round that featured a Lampard shot clearly landing beyond the goal line after hitting the crossbar but not ruled a goal.<br /><br />Hired by FIFA to help train top-flight referees, Larrionda admits he suffered through a difficult World Cup. Yet he believes his error led to a positive change; the convincing of FIFA president Sepp Blatter that GLT was needed.<br /><br />"It's for the global benefit of the sport,'' Larrionda regarding the use of technology. "It's all about protecting the game and to have credible soccer."<br /><br />The Dec. 6-16 FIFA Club World Cup in Japan will test both the systems approved by FIFA: the British system Hawk-Eye that uses multiple cameras to track the ball, and the German-Danish project GoalRef that uses magnetic sensors in the goal frame to monitor a special ball.Dougnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-89633920467462311872012-09-28T21:08:07.781-04:002012-09-28T21:08:07.781-04:00Beyond agreeing of course with your view, I'll...Beyond agreeing of course with your view, I'll note that my wife is the ninth-great-granddaughter of Rebecca Nurse (Nourse) (<a href="http://en.wikipedia.org/wiki/Rebecca_Nurse" rel="nofollow">Wikipedia</a>), the last woman hanged in the witch hysteria. Her home still stands in Danvers, MA, formerly known as Salem Village.<br /><br />Of peripheral interest is the genetic right-ear deafness in the family, affecting my wife and many relatives. (A family reunion could serve as a hearing aid store.) Some accounts say the last straw, to the judge, was her failure to answer some questions. The judge sat at her right. (Who knows if that was a factor.)<br /><br />I'm not an expert on the history but as I recall, the next woman accused by the children happened to be the governor's wife. At that point he decided enough was enough. It appears that wife was quite lucky that her husband liked her.<br /><br />e-Patient Davehttps://www.blogger.com/profile/16381434866099596466noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-90343871122997849412012-09-27T22:49:33.020-04:002012-09-27T22:49:33.020-04:00To Bill; 'rare event' depends on the width...To Bill; 'rare event' depends on the width of your definition of similar events. In my hospital, an axillary lymph node dissection on a cancer patient was once thrown out with the trash instead of sent to pathology - granted, not the exact same situation, but the system problems leading to it may be the same - or they may not! And that's the problem, there is never enough public information for these judgements to be made. As regards this case, a newspaper article today said a Texas transplant surgeon hired to investigate stated there were no systemic or cultural problems to indicate the hospital might be at risk for such an incident, and that the nurse had not followed standard surgical procedure. Now, on what basis might he be making that judgement? I doubt there are standards to back up either component of that statement.<br />Since we are never given the full story (or, not till months later), learning opportunities are quashed early.<br /><br />nonlocalAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-85800601493309271442012-09-27T19:43:03.315-04:002012-09-27T19:43:03.315-04:00It was beyond discouraging to read the hospital’s ...It was beyond discouraging to read the hospital’s response. I guess we can’t expect a complete culture change yet, but how many examples do we need?Briannoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-24869612508954421872012-09-27T19:23:06.488-04:002012-09-27T19:23:06.488-04:00From a quality and safety chat room:
This presuma...From a quality and safety chat room:<br /><br />This presumably was an extremely rare event, i.e. it has not been reported previously. As such it is extremely unlikely to occur again even without any intervention. As a result any intervention is virtually guaranteed to be successful, i.e. the event will not occur again. Then the investigation and the intervention will be declared to be a success, if anyone even tracks the post intervention period.<br /> <br />Does anyone remember "may your house be safe from tigers"? In most parts of the world that wish will be successful.Billnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-53371628355603901612012-09-27T09:49:03.994-04:002012-09-27T09:49:03.994-04:00This is beside the point, but there HAS to be more...This is beside the point, but there HAS to be more to the story in that Ohio case. NOTHING leaves the OR, not even a bag of trash, until the case is done and the patient is out of the room. Ever. (if the sponge count is incorrect at the end of the case, everything in the room is searched to find the missing sponge; in most cases, it has been simply misplaced or accidentally tossed, not left in the patient.)Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-33645323439238388002012-09-27T07:43:00.465-04:002012-09-27T07:43:00.465-04:00Many thanks Paul for your thorough and emotionally...Many thanks Paul for your thorough and emotionally touching story. What counts in a car plant for a faulty car, or just a part, may lead (as described) to loss, or severe damage of human life. <br /><br />Seeing the systemic dynamics is not what is taught nowadays at school, university or upper levels - so one can not blame the individual, nor the system. What becomes clear that the individual entrenched in the system has almost no chance to gain a broader view in order to learn about the possible impacts of his/her action in the context of the system.<br /><br />What has brought me to writing this comment, and in the first place pulled me into reading your story is the double attendance at Hans Werner Henze's "Wir erreichen den Fluss / We come to the River". The story though playing in war times, pretty much shows the unintended impacts of individual behavior on a system (due to the structure, and the mental models at play in this system). Perhaps my review (even though in German) can bring another facet into the understanding what makes leadership decisions, and behavior today in changing times, even more important than ever.<br /><br />See http://leanthinkers.blogspot.com<br /><br />Best regards from Dresden<br />RalfRalfLippoldhttps://www.blogger.com/profile/15149352083082630755noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-89527474380031786552012-09-27T07:16:24.090-04:002012-09-27T07:16:24.090-04:00Paul - well said. The failure to be personally acc...Paul - well said. The failure to be personally accountable is running rampant in many aspects of our lives – from finance to football… The reality is that in healthcare, in our hospitals, the end game is a lot more important.<br /><br />I have been fortunate to spend time with Linda Galindo who wrote The 85% Solution http://www.lindagalindo.com<br /><br />Her work is a reminder that when we use phrases like “personal” before the word “accountability” it resonates more with us as leaders, instead of being able to put it in the third person, as if accountability is something you do to people as oppose to taking it for yourself.<br /><br />Personal accountability is the willingness, after the event, to answer for the outcomes – good, bad, indifferent and ugly. Standing around blaming, pointing fingers and doing the “woulda, shoulda, coulda” is a complete waste of time, money and other resources – not to mention the fact that in the space of healthcare it is reprehensible for the patient, family, caregiver and others that are impacted by error.<br /><br />Personal accountability becomes a natural way of leading when you acknowledge that, as leaders, we are the culture, and every day we either choose to empower ourselves and take the personal ownership to commit to results, or not – the beauty of this is that the choice is ours. If the choice is that we like what we see and want to keep blaming others, as so eloquently stated by Paul Wiles, those talents may be better placed elsewhere. If it is to be it is up to me…<br /><br />Thanks Paul.Richardhttps://www.blogger.com/profile/11878659218770225605noreply@blogger.com