Book Synopsis #3 101 Ways to Prevent Medical Errors by Yinka Vidal

Synopsis #3: Chapter 5 - 6


Chapter 5

What Went Wrong in Hospitals?

This chapter deals with those conditions which created problems in hospitals and health care institutions leading to a proneness of to make medical errors. Unlike chapter one which deals with the history of the problems, this segment of the book discusses policies in place that have contributed to medical errors. It gives a manager or hospital director an opportunity to reevaluate those policies in place over the years that might have contributed adversely to patient care. Unfortunately, some of these policies have hurt not only the patients, but the employees as well, and in some cases, hurt the business. This is not an attempt to persecute any institution for their position on different issues of operation. It is neither a section to discuss the philosophy of profit versus not for profit. But, it is an opportunity to review systems in place and work to create a balance between cost containment and the quality of care being delivered to patients.

In this section of the book, ten major issues are discussed:    

1.      Implementation of strategies by over-exuberant managers to reduce cost leading to increased reduction of staffing and dangerous shortage of help.

2.      Introduction of  the authoritarian manager with the model of  "Yell at the Coach," causing many technical and middle managers to be targets of abuse by the system. Systemic problems went unresolved and medical errors escalated.

3.      Removal of Jesus Christ's Mission of Mercy and taking God out of hospitals.

4.      Detachment of the administrative part of the hospital from the clinical problems and operations.

5.      Favoring one department over another by the administration as perceived by the workers. This type of hospital politics prevented problems from being adequately addressed.

6.      Hindrance to effective communication caused by professional arrogance.

7.      Creation of systemic problems due to hostility in communication between hospital workers and how it has created a lot of systemic problems.

8.      Utilization of the blame game and punitive action instead of adopting corrective action.

9.      Replacement of "traditional medicine" with "assembly line medicine," leading to more medical errors.

10.  Discontinuation of the Laboratory Medicine department due to cost reduction.

Chapter 6

Urgent Actions to Correct Systemic Problems Within the Hospitals (the risk management and the quality assurance departments of the hospital should pay closer attention to this chapter)

Before dealing with technical errors caused by systemic problems, certain issues needed to be highlighted for urgent attention. These issues will be of great help to hospital administrators, executive officers or those managers who work only at the administrative level. In this chapter, possible root causes of medical errors are discussed. This discussion includes dealing with possible solutions by looking at generalized and non-technical problems. Any hospital executive willing to take up the task can easily ignite the process of finding solutions. For any of the solution strategies to work, the hospital administration must help to create a conducive atmosphere for problem identification, solution implementation, and measurement of outcome.

Here is a list of the action plans and "how-to" discussed in this chapter. They are issues of immediate concern to many hospitals:

1.      Evaluating the quality of service to patients.

2.      Work to improve patient identification throughout the hospital.

3.      How to protect the institution from legal liability.

4.      Importance of evaluating staffing and staffing needs.

5.      How to protect hospital administrators and business managers from litigation or criminal prosecution.

6.      The value of reevaluating all emergency room standing orders.

7.      Why any phlebotomist should never leave unlabeled blood tubes in a patient’s room.

8.      Understand the danger of last minute surgery without prior Blood Bank workup on a patient. Why surgeons should be educated about Blood Banking and the inherent danger of blood transfusions.

9.      Why all specimens giving suspicious panic results must immediately be reordered and redrawn before treatment.

10.  Why "pen-pushers" who make clinical decisions must work the bench or the station at least once a week.

- - - - - - And much more. This chapter also discusses the guidelines for a problem solving committee meeting.


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