tag:blogger.com,1999:blog-32053362.post8045443270539631535..comments2024-03-26T00:25:34.026-04:00Comments on Not Running a Hospital: Hey, UPMC! Head to New Zealand to learnPaul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.comBlogger3125tag:blogger.com,1999:blog-32053362.post-22122749738876205612011-11-21T16:38:26.131-05:002011-11-21T16:38:26.131-05:00How coincidental that this commentary entitled &qu...How coincidental that this commentary entitled "A Blueprint for Patient Safety" by Dr. Lucian Leape was 4th on the 'most emailed' list of the Boston Globe today (just behind the Red Sox):<br /><br />http://www.boston.com/bostonglobe/editorial_opinion/blogs/the_podium/2011/11/_by_lucian_l_leape.html?p1=Well_MostPop_Emailed6_HP<br /><br />If UPMC doesn't want to read the entire report, just absorb this pearl:<br /><br />"That’s precisely why transparency in responding to adverse events is so important. In order to improve the faulty systems, we have to understand them: what went wrong and why. Only by acknowledging errors and investigating them can we avoid them in the future."<br /><br />nonlocal MDAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-78210127000369510772011-11-21T15:28:21.742-05:002011-11-21T15:28:21.742-05:00Slightly off-topic here but did you see this story...Slightly off-topic here but did you see this story in yesterday's Atlanta Journal-Constitution? http://www.ajc.com/news/hospital-mistakes-kept-secret-1233859.htmlAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-54512217889667302282011-11-21T07:52:29.655-05:002011-11-21T07:52:29.655-05:00I particularly like these:
--"Errors aren’t ...I particularly like these:<br /><br />--"Errors aren’t intentional, they don’t improve through punishment and they’re hard to predict."<br /><br />--"If somebody else could make the same mistake, it’s a systems error."<br /><br />I'll also repeat the line that Jim Conway (of IHI fame) says he's used hundreds of times:<br /><br />“Our systems are too complex to expect merely extraordinary people to perform perfectly 100% of the time. We as leaders must put in place systems to support safe practice.”<br /><br />And that is from a man whose mother WAS killed by a medical error.<br /><br />I hope the leaders at UPMC can see their way through the apparent criticism, and glimpse a future where they simply won't have the need to decide whom to punish, because systems have improved.<br /><br />Please, all here, if we believe the leaders themselves made an error, let's apply the same thinking to them. Let's hope they can say: "On second thought..."e-Patient Davehttps://www.blogger.com/profile/16381434866099596466noreply@blogger.com