Medical Errors Report: October 31, 2003

Report of a 27-Year Observational Study on Medical Errors and Systemic Failures Within the Health-care System

Chicago Seminar on Fixing Medical Errors and Systemic Failure - June 1, 2004

Summary Report: A Four-year Solution Implementation Study   

List of Contents

Introduction

Slow Progress Persists in Fixing Medical Errors

Medical Errors Are Partly Responsible for Increase in Malpractice Insurance

To Achieve Continuous Quality Improvement, Hospital Administration Needs to Listen to Those Working on the Frontline

Better Results Can be Attained from Those Who Work on the Process-line

Hospital Administrations Need to Resolve Management Crisis to Attain Quality Improvement

Communication in Health-care Needs Urgent Improvement

Communication Breakdown Leads to Medical Errors

Hospital Management Needs Redesign to Face the Challenges of the Future

A Disconnection Between Middle and Upper Management Retards Quality Improvement

Increase in Workload Forces Employees to Take Shortcuts, and Compromising Quality of Care

Workable Quality Improvement Must be Initiated and Supported by Upper Management

Low Emotional Intelligence Reduces the Quality of Patient Care

Health-care Workers Need to Accept Constructive Criticism

Self-Transformation is Needed Before Fixing other People’s Problems

Sex Bias in some Areas of Health-care Impede Progress of Quality Improvement

Lack of Conducive Atmosphere Impedes Solution Implementation

Tapping into the Knowledge Base of Older and Experienced Employees Can be Helpful to Process Improvement

Occasional Medical Error is Different from Performance-Improvement Problems

A Swiss-Cheese Model Does not Create Medical Errors

Lack of Effective Utilization of Employees’ Time Costs Institutions Money

Indecisiveness Reduces Effective Implementation of Solutions

Medical Errors Drains Health-care Revenue

Improvement in Quality of Patient Care Saves Money

Avoid Using the Power of Office to Make Committee Decisions

Managers Need More Education About Using Team to Solve Problems

Hospital Managers Need to Develop Organizational Skills

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

Reducing Territorial Defenses Helps to Accentuate Team Work

Building Positive Relationships Helps to Solve Interdepartmental Problems

Improving Relationship with Coworkers Improves the Quality of Care

Behavior Modification Professionals Are Needed in Hospitals

Traumatized Health-care Workers Need Professional Help

Physicians Should Play Important Roles in Fixing Medical Errors

Physicians Need to Police Other Physicians

Three Different Group Approaches Can Reduce Medical Errors

Three Different Group Approaches Can Reduce Medical Errors

Some Generic Drugs Do not Work as Well as the Brand Name Drugs

Hospitals Must Be More Proactive in Quality Improvement Rather than Colorful Slogans

Expect Mass Casualties on Doomsday if Preparedness Remains the Same

Most Emergency Rooms Across the Nation Need Redesign

Indiscriminate STATS Reduce the Efficiency of a Hospital Lab

Bad and Confusing Procedures Lead to Medical Errors

Complicated Computer Systems Lead to Systemic Failures

Wasting of Government Money on Useless Research Projects Adds to the Failure of Fixing Medical Errors

Solutions to Fixing Medical Errors is Centered on Process Redesign and Administrative Active Support

Note: This is a small segment of the book: Managing Crises on the Job - An Interminable Journey to Fixing Medical Errors by 'Yinka Vidal, BS. MA. H.ASCP Published by Lara Publications and due to release summer 2004.

The Rest of the Book: Managing Crises on the Job

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