101 Ways to Prevent Medical Errors

Press Release: January 2003
News Report: Forthcoming Documentary – Discovery Channel

Making of a Documentary: How to Prevent Medical Errors

'Yinka Vidal, BS. MA. HASCP. and Max Cohen, MD. being interviewed for the television segment of the documentary by Bill Hockhauser of the Film Garden Entertainment of California.

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Left is 'Yinka Vidal, the author of 101 Ways to Prevent Medical Errors during the television interview for the documentary

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Left is Max Cohen, MD.  the Vice President and Medical Chief Officer Missouri Baptist Medical Center

Film Garden Entertainment of Hollywood, California is producing a documentary called Medical Errors and Solution Intervention for the Discovery Channel. This program is to be aired in the spring of 2003. The documentary will include a few cases of medical errors across the nation and interviews with experts on how to prevent such problems in the future. The program is different from other news reports about medical errors because it discusses solution intervention.

 St. Louis, Missouri, will be featured in the solution segment of the documentary. Again, the Show-me State will show the whole nation how to solve the riddle of medical errors. In the solution segment of the documentary, two experts from Missouri will be featured in the program. Yinka Vidal, BS. MA. H.ASCP., and Max M. Cohen, MD. MHSA. FRCSC. FACS. FACPE.,  are being interviewed about their national studies on how to prevent medical errors. ‘Yinka Vidal, the author of 101 Ways to Prevent Medical Errors and the Chair of the National Campaign to Prevent Medical Errors, has been working on medical errors for 25 years. He started working on solution intervention more than three years ago. He has written two books on the subject matter and is presently working on the third one. In his interview, he stresses that medical errors are not caused by a complex health-care system, but rather by “simple systemic failures.” He describes American medicine as being the best in the world and states that the United States spends more money on the advancement of medical research than any other nation. “But, there are defects in the processes of delivering care; those defects manifest themselves as simple systemic failures,” says ‘Yinka Vidal.

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The best way to fix the problem of medical errors is to work directly with each of the processes of delivering care, find the are defects and fix them, as he emphasizes in his seminars to health-care workers. There is hardly any problem leading to medical errors that cannot be resolved through process redesign, says the author.In this way, processes can be reprogrammed to reduce the chances of errors. Another source of problem is the computer systems used in many hospitals and their inability to spot errors.

Most hospital computer systems are not designed with effective checks and balances to avoid errors. Also, some of them are not designed to handle the volume of information traffic being generated on them. The initial primary goal of most hospital computer systems was to allow delivery of information through automation. Today, we have to go back and redesign most of the systems with embedded safety factors to reduce errors. When errors occur, “checks and balances” can be built into the system to prevent the propagation of such mistakes down the process-line of care. In a case where error causes harm to a patient, immediate corrective action should be taken to remedy the situation and prevent further suffering or damage to the patient. But, this cannot be done without looking at the entire process of care.

 “Solution design resulting from root-cause analysis is not as difficult as many people may think. But, the greatest challenge lies with the processes of solution implementation,” stresses ‘Yinka Vidal, the author of 101 Ways to Prevent Medical Errors and the Managing Editor of OUTCRY Magazine. The hospital administrations must work hard to “buy-in” employees on new ideas while workers must be energized to achieve positive results! He explains that for solution intervention to be successful, three major components must be present. First, the process of delivering care must be evaluated for defects, and the system must be redesigned to prevent errors. Second, health-care workers must be made receptive to improvement strategies. Third, health care institutions must foster the environment for the successful implementation of solution intervention. For more information on solution intervention, and why medical errors continue, read the article on Why Medical Errors Continue – Part II: Solving the Mystery of Medical Errors,  by ‘Yinka Vidal - - - coming soon.

 Dr. Cohen, the Vice President and Chief Medical Officer of the Missouri Baptist Medical Center, is also featured in the solution-implementation segment of this documentary.  In the interview, Dr. Cohen points out that humans will always make mistakes. But, when errors occur, mechanisms should be put in place to prevent such errors from occurring again. As humans, we are unwilling to accept the reality that we make mistakes. In health care, as in any other industry, mistakes are very common. In the past years not a lot of changes have taken place regarding medical errors. He indicates that the total cost of medical errors greatly exceeds $10 billion annually. In response to questions directed to him, Dr. Cohen gives some hints to other health care professionals to help prevent errors.  He stresses that surgeons should be careful not to leave any surgical instrument inside a patient. A modern anesthetic machine will monitor vital sign parameters, and it should be calibrated and be in good working condition. He indicates that most hospitals are equipped to deal with emergencies, and the out-patient surgery department should be regulated with the same guidelines as the regular hospitals.

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During the interview Dr. Cohen said one of the most remarkable things regarding medical errors. He stresses throughout the interview that a non-punitive approach is the best way to address medical errors when they occur. He also emphasizes that errors are not caused by bad people, but by  defects in the processes of care. The most amazing thing said during the interview is, “Medical errors claim two victims; the patient, and the health-care workers.” Nobody has ever discussed the emotional pain and suffering of the health workers involved.

in this interview, Dr. Cohen is the first person in the nation to bring that issue to light. He tells the public about the suffering of the patients, and that of the health care workers involved. He indicates that there is hardly any health care worker involved in an error who is not traumatized because of it. The solution to medical errors is to fix systemic problems and put mechanisms in place to prevent them from happening again.

 This type of documentary is very different from most other media reports about medical errors. In the past, most news reports on medical errors were centered on problems without discussing solution intervention or what hospitals were doing to remedy the situations. Consequently, many health care workers and health care institutions shy away from such reports because they create sensationalism, rather than help to explore solutions. Although many hospitals are working to solve the problems, their efforts are hardly rewarded by the media’s lack of interest in reporting about different solution strategies. The Discovery Channel is leading the national media in discussing problems of medical errors and solution interventions. This is the first time a major national medium will be featuring solution intervention on medical errors and the barriers encountered by those working to reduce these errors. Such a program on the Discovery Channel is very important and laudable because it will educate the public about what health-care institutions are doing to prevent errors. It will also teach patients how they can help to be a part of their treatments, as well as open a door for a public dialogue regarding solution interventions.

 For more information about the exact time and date the documentary will air, please visit www.101waystopreventerrors.com or www.discoverychannel.com 

 Bill Hochauser, Tom Taglang and Roshika Vannie of Film Garden Entertainment of Hollywood, California, produced the documentary for the Discovery Channel. Stay tuned for more information about the forthcoming documentary. This is a program that all health-care workers in the nation must see.


Making of a Documentary: See the Rest in Pictures

Press Release by Lara Publications, Florissant, Missouri, Dec. 2002

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