Medical Errors Report #22
A Four-Year Solution Implementation Study
Three Different Group Approaches Can Reduce Medical Errors
A problem solving committee does not have to be based on the same model throughout the hospital to achieve efficiency. Different committee approaches can be used in a problem solving group. At least three styles of committees exist for fixing medical errors. First, a committee can be designed according to the CQI in which those who work on the process-line comprise the majority of the team, directed by a team leader and facilitated by an administrative representative. Second, a team can operate from the hospitals quality improvement department. Such a team is made up of the director of quality improvement, two of her nursing staff, a physician, a minister, and an attorney. This team springs into action anytime a patient is harmed as a result of medical errors. The action of the team members includes discussion with the family members, root-cause analysis to find out what happened, solution design to fix the problems and implementation of such solutions. In the process of doing post-accident quality improvement work following medical errors, members must directly engage those who work on the process-line. Third, a quality improvement manager may be assigned to each of the major hospital critical department. The managers will be doing 50 percent bench work and 50 percent of quality improvement work. They will have to report either to the director of quality improvement or to the administrator over that department. For objectivity, they will not have to report to the director of the department in which they work. The director may however, be requested to give reports at the problem solving committee meetings and he or she can be a member of the problem solving committee. Once a month, all the quality improvement officers from different departments should meet to share ideas based on their experiences, about problems and solutions. When a problem occurs in a department, the quality improvement officer must create an action team within his or her own department, including at least one person from a complimentary department to work on the problem and find solutions. This quality improvement officer will be responsible for monitoring the quality improvement of the department.