Written by attorney James E. Girards | May 25, 2010

What every Patient Should Know - Hospitals fail to Adopt zero-defect Systems like other Industries

The hospital industry in the US is allowed to keep its inner operations secret. This is unlike any other industry. As a result, US hospitals have little pressure to adopt the same kinds of effective fail-safe systems that other industries have been using for years. In fact, the Joint Commission is so concerned about this that in the Fall of 2009 it sent out a "Sentinel Event Alert" to address the problem. The Joint Commission stated, that even though positive movement was occurring, "Health care organizations have not developed the “zero-defect" safety interventions seen in other high-risk industries such as aviation, energy and manufacturing. ( 8, 9)" This may surprise members of the public, but it is no surprise to attorneys who do medical malpractice litigation. The Joint Commission has placed the blame squarely on hospital leadership and has recommended that hospitals immediately do the following:

"The following suggested actions are directed to senior leadership—the governing body, the chief executive and senior managers, and medical and clinical staff leaders:

  1. Define and establish an organization-wide safety culture that includes a code of conduct for all employees, including contract workers.
  2. Institute an organization-wide policy of transparency that sheds light on all adverse events and patient safety issues within the organization, thereby creating an environment where it is safe for everyone to talk about real and potential organizational vulnerabilities and to support each other in an effort to report vulnerabilities and failures without fear of reprisal. ( 8, 9)
  3. Make the organization’s overall safety performance a key, measurable part of the evaluation of the CEO and all leadership. ( 3)
  4. Ensure that caregivers involved in adverse events receive attention that is just, respectful, compassionate, supportive and timely. Also, make sure they have the opportunity to fully participate in the investigation, risk identification and mitigation activities that will prevent future adverse events.
  5. Create and communicate a policy that defines behaviors that are to be referred for disciplinary action; include the timeframe that the disciplinary action should take place.
  6. Regularly monitor and analyze adverse events and close calls quantitatively and communicate findings and recommendations to leadership, the board and staff. ( 8) Conduct root cause analyses of adverse events. Look for patterns in root causes that identify latent hazards and weaknesses in the defenses against errors—the holes in the slices of cheese—and make sure they are addressed. ( 2, 14)
  7. Regularly hold open discussions with risk management, performance improvement, physician, nursing and pharmacy leaders, and with physicians and staff caring for patients, to develop a true, unvarnished view of the safety risks and barriers to safety facing patients and staff. Patient safety rounds at the point of care could provide the ideal opportunity for these discussions, which should focus on learning and improvement, not blame or retribution.
  8. Prioritize and address safety risks and barriers to safety according to a timeline, with the highest priority items getting immediate attention. Make a visible commitment of time and money to improve the systems and processes needed to defend against hazards and minimize unsafe acts. ( 2, 8, 14) For example, some organizations create an emergency patient safety fund.
  9. Establish partnerships with physicians and align their incentives to improving safety and using evidence-based medicine. ( 3, 14)
  10. Add a human element and a sense of urgency to safety improvement by having patients communicate their experiences and perceptions to board members, executive leadership, medical staff, and other key leadership groups; also solicit patient input into safety design. ( 14, 23, 24)
  11. When planning and implementing safety improvements, use the expertise of front-line staff who understand the risks to patients and how processes really work. ( 8, 14)
  12. Regularly measure leadership’s commitment to safety using climate surveys and upward appraisal techniques (in which staff review or appraise their managers and leaders).( 14, 25)
  13. When leaders assess managers during the annual performance review, make sure they ask about the safety issues the manager encountered, how they were handled, and the impact their actions had on reducing unsafe conditions.
  14. Communicate to staff when their work improves safety. Reward and recognize those whose efforts contribute to safety."

If you or your loved one has suffered a severe injury or death as a result of unsafe hospital practices, please contact [email protected] for more information.

Additional resources provided by the author

The Sentinel Alert mentioned above can be downloaded at the link below:

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