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Women and Infants responds to error report

November 17, 2010

This afternoon I met with Dr. Raymond Powrie- Women and Infant’s senior vice president for Quality and Clinical effectiveness.

He scored points right away because he said he liked my blog, but I was also impressed by his approach to talking about these mistakes.

Powrie’s take on preventing errors put more responsibility on the hospital than it did on the doctors who made the mistakes.

“No one intends to cause harm to their patients. What we usually find when things go wrong is the primary problem is our systems are not built as safely as they could be. One of the adages that we live by is ‘our job is to make it easy to do the right thing and hard to the wrong one.’  So if a doctor or nurse comes in, has had a fight with their spouse in the morning and is distracted by that,  we make the systems as good as possible so they can never be put in a situation where they accidentally cause harm to their patients. “

It’s a tricky balance between punishing the people who make these mistakes and listening to them.  Of course, folks need to be held accountable for their actions, but those individuals are often warning signs for a much larger problem.

In this case, a policy that wasn’t clear enough about how to communicate during shift changes (the gauze was left inside a woman because the new shift didn’t know it was in there.) In the instance of the string, the system for making sure all of an object was removed after it had been recovered was  vague.

So, what do you do?  If hospitals or individuals are severely punished, there’s no incentive to report mistakes or mistakes that almost happened. Then those warning signs just go underground, where we can’t learn from them.

What do you think is the right approach for  responding to these errors?

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