Medical Errors Report #28

A Four-Year Solution Implementation Study

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

Much of this report indicates that many hospital executives are less responsive to initiatives to reduce medical errors. Some health-care executives questioned claimed that it was virtually impossible for them to fix problems identified in various hospital departments. They expect the department head to be responsible for such intervention. It was further explained that the hospital operation is big and they cannot be in all places at all times. How do they know that the system is working? Most of them responded that, as long as no problem is reported, they believe everything is working out well. According to Anthony Vecchione’s article, “Fine $1 Million Hospital Installs Narcotic Tracking” (Drugs Topic, Dec 16, 2002), a hospital was fined for violating the DEA inventory practice guidelines and failing to report missing narcotics. One nurse called to help the hospital indicated that the hospital needs a comprehensive team to look at processes and how they impact hospital operations. She also stated that neither the hospital policies nor the procedures met government requirements or JCAHO regulations.

 Some conversations with health-care workers including some physicians during this study make it obvious the present system is not working well in fixing medical errors and systemic failures. I also gather from these interviews that many of the health-care executives are as overwhelmed as employees who must do more work with less staffing. To some extent, some of them created their own administrative problems. Unfortunately, some of them spend more time and efforts collecting money for the United Ways than the amount of time they spend on quality improvement. It is also obvious that many of them are interested in improving quality of patient care because it ties directly to the hospital’s revenue. However, there is a major problem. Many of them do not know how to fix the problems. They think their only choice is to delegate. To achieve substantial and ongoing progress in error reduction, hospital executives must be more involved in quality improvement.

 Here is a rescue. The best way to fix medical errors is to first look at all the systems put in place to deliver care to patients from all the critical departments of the hospital. An investigator must keep in mind that most errors are not caused by the complexity of the system, contrary to what we were being deluded to believe. Most medical errors to-date, have been cause by simple systemic failures. The process of fixing these failures may however, be a little more complex because there is a lot involved in redesigning and implementing a new process. For example, one department may have a very elaborate collection of procedures. Each procedure has to be evaluated from the perspective of the process-line workers using these procedures to take care of patients. Most of the time, disaster turns on the red light. People wait until disaster strikes before igniting a process to evaluate what went wrong at which time it is too late. Being proactive is to identify problems before they happen and fix them before disaster strikes.

 Another observation from this study is the replacement of physicians with nurses, techs, pharmacist or business executives to be administrative heads over clinical departments. Many hospital administrations resorted to this type of management because they are able to   easily influence the techs or nurses more than physicians regarding financial issues. The impact created disastrous outcome for quality improvement as many of these physicians washed their hands off quality improvement issues. For examples, when pathologist were the administrative heads of the lab, they were not only involved in day-to-day operations of the lab, they were also the lab advocate with fellow physicians including being directly involved with quality improvement. During those years, pathologists set a list of tests to be done as STATs. Too many unnecessary STAT tests are costing hospitals millions of dollars every year in wasteful spending. Today, some pathologists do not want to get involved with quality improvement because of the hospital administration’s grip on management power. Since the hospital executive in charge of the lab does not know anything about the clinical operation of that department, pathologist must be place back in place of leadership and management. If quality improvement is to survive in clinical departments especially when it involves other departments like the nursing, physicians must be more involved in fixing errors. Removing pathologists or other physicians from presiding over clinical departments is one of those administrative blunders of the 1970 and the health-care institutions are paying dearly for it today.

 Many times in this study, we evaluated procedures that people are using and wondered how in the world they have been delivering services to patients. This situation is like a person sitting on a time bomb and smiling. What we noted is, when people to do understand a procedure, or when the procedure is too cumbersome, employees would develop their own personal procedure leading to variations and increased chances of errors. Most of the time they believe they are following the normal protocol. They would argue they are following proper procedure. But, when they are observed carrying out such procedures, variation leads to increase chances of errors.  In some departments like nursing, errors are often caused by employees in a hurry to get things done either because of lack of time to double check or because of lack of awareness of the danger of shortcuts. Other times, errors are caused by carelessness. Once deficiencies are identified in a process-line, solution is achieved through a process redesign, and implementation of the new design. People have to be very careful. Such an endeavor to fix a problem has to be done very carefully and correctly, according to guidelines to assure effective implementation. Lara Publications has created an answer for that problem with an in-house seminar to help hospitals achieve this objective. Please visit our website at

 Doing process redesign correctly is very essential. Many hospitals act as though they do not know how to effectively conduct process redesign to achieve the intended objective. Rules and guidelines must be followed, and there is a very important part the hospital administration must play. An untrained person cannot do this successfully because a lot of processes are involved including ways to deal with resistance and barriers when they arise. It is also very essential to understand the techniques for getting employees to buy-in the new process design. Many quality improvement officers still do not understand the process of motivating employees to accept, implement and absorb the new redesign. This is the primary reason why efforts across the nation to fix the problems causing medical errors have failed. This trend can change if we follow the correct guidelines.

 Most importantly, hospital executives must champion the campaign to improve quality of care in their respective institutions to help reduce medical errors. Health-care CEOs, medical directors and nursing vice president must make honest commitment to not only initiate quality improvement processes but must also be actively involved with various action groups working to fix errors. The present remote control strategy of the old management system where the executives dish out orders and expect solutions is becoming obsolete as a management policy or technique. Employees need to be motivated to take ownership, identify problems on the process-line and work with the system to fix them. This cannot happen in the absence of hospital executives championing the process. No amount of training, efforts or workshop programs will work to fix medical errors in the absence of administrative active commitment and involvement.

 The outcome of this report so far has both a bad and a good news. The bad new is the continuation of medical errors will continue to kill patients until health-care executives start listening to us – who are working on the process-line. Celebrity researchers who have no idea about what is happening on the process-line except for a few of them have no answers. Those researchers with big titles do not push patients to X-ray or to surgery. They neither draw blood, perform blood tests, take patient x-rays, dispense medication from pharmacy, receive telephone orders from physicians, give medications or transfuse blood to patients. Those researchers only based their assumptions of the problems on the data provided to them. The celebrity researchers have no answers, that is why after spending over half a billion dollars since 1999, medical errors are still killing patients due to simple systemic failures. The solutions lie with us who are not only working on the process-line but also studying systemic failures while taking care of patients. The good news is, reduction in medical errors increases when hospital executives are motivated and enchanted by incentives to champion the efforts to improve quality of care. Hospital executives must make quality improvement their number one priority just like they look out for the financial picture of the hospital.


The rest of the story and the detailed chronicle of war on medical errors during the implementation phase of solutions and the obstacles encountered are featured in the book: Managing Crises on the Job – Reported for Working on Duty and Reprimanded for Working too Hard – An Interminable Journey of Fixing Medical Errors, by Yinka Vidal published by Lara Publications, due for release in Summer 2004.


Reports (books) on the ongoing medical error reduction project

1.      Process Redesign – An Effective Way of Fixing Medical Errors and Systemic Failures – (publication date to be announced)

2.      Managing Crises on the Job – An Interminable Journey of Fixing Medical Errors - 2004

3.      101 Ways to Prevent Medical Errors – A 24-year Odyssey - 2002

4.      Overcoming the Invisible Crime - 1993

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