tag:blogger.com,1999:blog-32053362.post5925008308138360206..comments2024-03-26T00:25:34.026-04:00Comments on Not Running a Hospital: Lessons from near missesPaul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.comBlogger11125tag:blogger.com,1999:blog-32053362.post-67413083595677337582015-09-09T06:25:34.266-04:002015-09-09T06:25:34.266-04:00From Facebook:
We think the best lessons come fro...From Facebook:<br /><br />We think the best lessons come from success, but the reality is that they come from failures, and near misses.Roberta Brownnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-44067160783540765862015-09-08T22:10:19.283-04:002015-09-08T22:10:19.283-04:00Along with Jeff Cooper, I still think these should...Along with Jeff Cooper, I still think these should be called “near hits”, but I know it is hard to change the jargon. <br /><br />As for the case itself, one needs to differentiate whether the problem is inadequate circulating blood volume(e.g., from leaky capillaries as in septic shock), hypovolemia from blood or other external sources of fluid loss, inadequate cardiac output from pump failure(which can also occur in late septic shock), or profound vasodilation form various causes, including septic shock. In other words, a more complete assessment needs to be made quickly, although pumping in volume, as the doctor-father did is a good first rescue step. As usual, it is complicated and normally should not get to this stage, if as was suggested, a quick response by all concerned had occurred. Davidnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-88952034118003123482015-09-08T16:05:38.086-04:002015-09-08T16:05:38.086-04:00Following the tragic and very sad death of 18 mont...Following the tragic and very sad death of 18 month old Josie King from dehydration at Johns Hopkins in 2001, a rapid response team that parents could activate was put in place. Her mother, Sorrel King, was a strong advocate who helped bring about this change in protocol.<br /><br />As I understand it, there were early fears among medical professionals that family members would abuse the program by too often calling for the rapid response team when it wasn’t necessary. That turned out to be a wrong and unwarranted assumption. It might be helpful for hospitals that have rapid response teams that families can activate to share their experience about the number of times they’re activated by family members and how many were warranted vs. not warranted.<br /><br />I find it hard to understand how hospitals can justify not having a rapid response program that families can activate in place. How do they justify or rationalize that decision?<br />Barry Carolnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-45208565374142006022015-09-08T15:30:45.084-04:002015-09-08T15:30:45.084-04:00Paul, my old shop was a very early adopter of RRT&...Paul, my old shop was a very early adopter of RRT's, probably even before they were widely recognized - I am talking 10 years ago or more. It was in response to the hospital making the front page of the Washington Post for 3 deaths and an ensuing battle between the medical staff and the (previous) administration and Board. I believe it was an attempt to publicly demonstrate the hospital's new sensitivity to safety issues - but how sad that it took 3 deaths, a fired CEO, and a ruined reputation to get it done.nonlocal MDnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-74773999115610389022015-09-08T11:23:05.708-04:002015-09-08T11:23:05.708-04:00I respect and agree with nonlocal MD.
Looking forw...I respect and agree with nonlocal MD.<br />Looking forward to the three questions Mr. Levy asked, being answered please. Carolehttps://www.blogger.com/profile/02916598876575236275noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-2802806788825134612015-09-08T10:11:18.511-04:002015-09-08T10:11:18.511-04:00One other angle to consider... why does it take th...One other angle to consider... why does it take the patient being a loved one for surgeons or others to "wake up" about the problems in hospitals?<br /><br />Some hospitals talk a good game about "treat every patient as if it were your mother" (or whatever relation you'd want to choose).<br /><br />The same process and system errors occurred before it was his daughter in the bed... and I bet they still continue?Mark Grabanhttps://www.blogger.com/profile/07953086531083611251noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-80342918419793969462015-09-08T08:04:46.862-04:002015-09-08T08:04:46.862-04:00Sadly, if you work in a place with the rapid respo...Sadly, if you work in a place with the rapid response team process you describe, you work in an unusual place. Many hospitals still do not recognize the need.<br /><br />That being said, I'm willing to bet your hospital did not have such a system in place just a few years ago. So, the interesting question is how did the leadership of your place come to see the light? What was noticed? How did the change occur?Paul Levyhttps://www.blogger.com/profile/17065446378970179507noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-70465959004373689722015-09-08T07:40:36.450-04:002015-09-08T07:40:36.450-04:00I don't understand how this could happen.
In ...I don't understand how this could happen.<br /><br />In our hospital, anyone, even family members of patients, can call an RRT---which would qualify based on her pulse rate alone. We communicate this to our patients and their support team when they are admitted.<br /><br />The fact that the nursing staff did not recognize this as an event worthy of an RRT is very troubling.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-66666043401480634632015-09-08T06:57:22.869-04:002015-09-08T06:57:22.869-04:00From Twitter:
Some 'patient and family escala...From Twitter:<br /><br />Some 'patient and family escalation of care' at @NSWHealth http://www.isqua.org/docs/edinburgh-powerpoint-presentations-2013/1235-c12--karen-luxford-kilsyth-wed-reach-patient-and-family-activated-escalation-of-care.pdf?sfvrsn=2Jen Morris @JenWordsnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-16492975240125923622015-09-08T06:40:08.244-04:002015-09-08T06:40:08.244-04:00From Twitter:
Near-misses feel like a blessing - ...From Twitter:<br /><br />Near-misses feel like a blessing - a chance to understand and fix a problem before anyone is harmed.Marie Bismark @mbismarknoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-57616915296276339782015-09-08T06:20:17.409-04:002015-09-08T06:20:17.409-04:00I wonder if the lack of followup on near misses mi...I wonder if the lack of followup on near misses might be due to our overweening rescue complex in medicine - i.e. the near miss was 'rescued', by whomever it might have been, and everyone congratulates themselves on a job well done and moves on. Instead of realizing there shouldn't have been a near miss in the first place and they should be worried as hell.<br /><br />nonlocal MDnoreply@blogger.com