tag:blogger.com,1999:blog-32053362.post8025710035090856577..comments2024-03-26T00:25:34.026-04:00Comments on Not Running a Hospital: Tracking adverse eventsPaul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.comBlogger5125tag:blogger.com,1999:blog-32053362.post-10421174517491539852012-01-10T18:21:33.597-05:002012-01-10T18:21:33.597-05:00We have a fabulous high-tech incident reporting sy...We have a fabulous high-tech incident reporting system called "Occurrence Insight." It is used mainly by tattle-tales whose feelings have been hurt. Seriously, one nurse recently took some paid time to "write up" another nurse for sighing heavily over the phone.<br /><br />Yet a medication error near miss that happened during the same month went officially unreported.<br /><br />Garbage in, garbage out.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-32892828713728103822012-01-09T14:05:26.869-05:002012-01-09T14:05:26.869-05:00Actually, Keith, I wasn't frustrated at BIDMC,...Actually, Keith, I wasn't frustrated at BIDMC, and our market share actually grew substantially as a direct result of our focus on quality, safety, process improvement, and transparency.Paul Levyhttps://www.blogger.com/profile/17065446378970179507noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-57021593334094701702012-01-09T11:06:27.016-05:002012-01-09T11:06:27.016-05:00Once again, until the incentives are changed, do n...Once again, until the incentives are changed, do not expect health care administrators to alter their priorities.<br /><br />Despite the fact that many mission statements of hospitals usually state their missions to preserve life and improve health, their main missions have become one focused more on growth and dollars; just what CEOs are taught to focus on as their priorties. While most corporations would fail with a strategy that increased the cost of its product and reduced the quality, healthcare measures of quality are difficult to obtain, and health insurance shields the consumer from the true cost. Why else do we have waterfalls in hospital lobbies, concierge service at most upper tier hospitals, and a barrage of hospital advertising? Are they really a necesity to the hospitals mission?<br /><br />I think you constantly show the profound frustartion you undoubetedly experienced in improving the quality at BIDMC, but watching as a probably inferior system in terms of quality ate at your market share as they used their extra premium dollars to buy up more hospitals and doctors practices. It is no fun feeling you are doing the right thing to try to improve healthcare and to watch as others work to shovel more money into their pockets while placing our healthcare system on an unsustainable economic path.Keithnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-86849041028018924492012-01-09T08:17:27.106-05:002012-01-09T08:17:27.106-05:00Paul, you are so right to emphasize the importance...Paul, you are so right to emphasize the importance of the near miss, and of the front line staff in designing error collection and management. I had a seminal experience as Blood Bank medical director in my hospital, where the process for maintaining patient identification for blood transfusion during surgery was deficient. (Sadly, our hospital had an old history of killing a patient through a transfusion ID error) The OR nurses all knew there was a problem and, individually, had devised workarounds that they thought would compensate - including such things as writing the patient's medical record number on the leg of their scrubs! The OR Director and Nursing VP tried to devise nonworkable solutions off the cuff during a meeting with me in their office - clearly to make me go away as soon as possible.<br />When I was finally allowed to meet directly with the staff, they arrived at a consensus solution, implemented it and were off and running. Many approached me later expressing gratitude that this worrisome problem had finally been addressed.<br /><br />Imagine a world where senior management would encourage the relentless identification and front line-driven solution of such accidents waiting to happen. Wouldn't we want that as patients?<br /><br />nonlocal MDAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-1279798076869916212012-01-08T23:38:17.815-05:002012-01-08T23:38:17.815-05:00There is something gratifying to see in print what...There is something gratifying to see in print what we all knew, and said, but was long taboo to agree upon.<br /><br />What would be bold? <br />(1) Garner some fraction of current technological transitions to reliably capture a portion of 'overlooked' events to increase the individual cost of moving on to the next patient,<br />(2) Recruit the interests of those who do not report because of hierarchical concerns by elevating anonymous (provider and reporter) reporting systems (governmental and independent organizations should do this if institutions do not),<br />(3) Create meaningful local rewards for the humility of making a mistake, and the courage to share it (velocity could be gained from leaders being leaders by doing so first),and,<br />(4) Centralize patient/family reporting similar to the airline pilot model. If we are talking about it at with such frequency over dinner and the watercooler, why not TwitterHarm?<br /><br />One or two of them, well executed, would push the behemoth off its spin. It isn't necessary to change everyone's behavior. Just create the unpredictability inherent in a life without immunity. It is the world that most of us live in each day.Anonymousnoreply@blogger.com