Medical Errors Report #18

A Four-Year Solution Implementation Study

   Quality Improvement Officers Are Unable to Influence any Change Without Enforcement Power from the Hospital Administration

One of the observations made was the hospital’s quality improvement officers lack of power to influence a positive outcome within the system. The department concerned just refused to listen. According to Patrice Spath (Brown-Spath Associates, March 2002), although quality improvement officers know what to do, they do not have the power to effect organizational change that senior leaders do. She indicates that CQI has failed in some organizations because its utilization is pushed down to people lower in the organization. She urges that hospital upper management should be involved by building a culture where patient safety improvement is on top of the hospital’s agenda

 During our study, we encountered a similar situation when the endoscopy department refused to respond to corrective initiative after five mislabeled surgical specimens were reported within a week. It was a battle to get the department to respond to the quality improvement council despite persistent efforts to remind the department about the danger of such errors causing the misdiagnosing of patients. In the end, the issue was reported to the Vice President of Nursing who later intervened, leading to response from the endoscopy department. Even then, the nursing director of the endoscopy department failed to file an action plan with the hospital quality improvement council as was requested. In another hospital, a small amount of the wrong blood was given to a patient because the transfusing nurse did not look at the patient’s identification armband. The patient must have received about 20 cc of the wrong blood. When the lab contacted the risk management department in regard to a subsequent action-plan, the answer was, “nothing.” The lab was expecting risk management to follow up the incident with a root-cause analysis, look at the process and design ways to prevent the problem from happening in the future. Risk management refused to do anything in this particular case because, according to the department, no harm was done.