“Hey, Julie, I’ve been doing some spring cleaning.”
“Your messy office or your cluttered basement?”
“My office is not messy,
but my files are overloaded. I’ve
been sorting them to discard the junk and retain the classics. Although this stuff goes back to 2006,
the gems shine as brightly as they did originally.”
“Then, Curmudge, let’s share some of them with our
readers. They are all quotations,
but we won’t have room for complete references. Perhaps we can just state the name of the author or the blog
or publication in which the quote appeared.”
“Okay, Tonto, you type while the Lone Ranger shuffles
papers:”
“99,000 patients
die each year as the result of hospital-acquired infections and errors. That’s the equivalent of one
fully-loaded 747 crashing each day for 200 days out of a year. About 7,000 people per year are
estimated to die from medication errors alone with three-fourths of the adverse
drug events due to failures at the system level.” (Graban 8/09/09)
“Curmudge, I find
these numbers astonishing, yet the original sources of these values are quite
believable.”
“The only way to crack down on error is to admit its inevitability. Being aware of the mistakes we make
that lead to error is the only way to curb it.” (K. Schultz in ‘Being Wrong’)
“After surgical technique, most surgical error was caused by human
factors: judgment, inattention to detail, and incomplete understanding, and not
to organizational/system errors or breaks in communication.” (pubmed/18847639)
“In the arena of skill- and experience-based errors, the research is
clear. Nothing can take the place
of repetition.” (emsresponder.com)
“Checklists seem able to defend everyone, even the experienced, against
failure in many more tasks than we realized. They provide a kind of cognitive net. They catch mental flaws.” (A. Gawande)
“About 15 percent of patients are misdiagnosed. In fact most cases are due to mistakes
in the mind of the doctor.”
(Jerome Groopman)
“Studies have demonstrated that geographical location strongly
determines specialty care access and procedural decision making.” (Harrington, Quality Digest, 2006)
“In Pennsylvania alone, the mortality rate during a hospital stay for
heart surgery varies from zero in the best-performing hospitals to nearly 10%
at the worst performer.” (NY
Times, 5/17/07)
“There’s also a very complex social and organizational hierarchy that
makes it difficult for people lower on the hierarchy to critique or speak up
when they see a problem with someone higher up.” (WebM&M, Nov. 2006)
“All health care providers performing invasive procedures must adopt the
Joint Commission Universal Protocol, including performance of a time out
immediately prior to the procedure.”
(medscape.com/17053)
“Out-of-hospital sudden cardiac arrest survival to discharge generally
reported at less than 10%, and survival from in-hospital sudden cardiac arrest
estimated at 18%.” (WebM&M,
July/August 2007) “A 2010 study of
more than 95,000 cases of CPR found that only 8% of patients survived beyond
one month.” (G. Hood, 4/16/12
Medscape)
“Please note,
Julie, that if one ‘codes’ in a hospital and somehow manages to survive, he
still has his original ailment, and in addition, a crushed chest.”
“Wow, Curmudge, I can
see why old guys like you in a hospital want their chart to indicate ‘Do not
resuscitate.’ ”
“(A patient safety officer’s) job ethically is to transparently promote
a reliable and safe environment.
To do that, you need transparency.” (A. Frankel, MD, WebM&M, Dec. 2006)
“The single greatest impediment to error prevention in the medical
industry is that we punish people for making mistakes.” (L. Leape, 2008)
“Environmental cleaning is so important that when it is not done
regularly and rigorously, placing a patient in a room previously occupied by a
patient with Clostridium difficile can be a fatal mistake. Cleaning hands with soap and water is
essential, because alcohol sanitizers are often ineffective against C.
diff.” (hospitalinfection.org,
Jan. 2009)
“There is compelling evidence that performance measurement leads to
performance improvement.” (However) “Good performance is not necessarily good
care, and pressure to improve performance can come at the sacrifice of good
care.” (R. Werner, Medscape
555953)
“For employees, it is the culture of the organization that is the
reality, not the mission statement that hangs on the wall.” (A. Yelton, GE Healthcare)
“Lean Thinkers now have the tools to reform healthcare delivery.” (Jim Womack)
“It takes 18 years for proven best practice to become the industry
standard in healthcare.” (Brent
James, 2009)
“I was hoping,
Curmudge, that we would find quotations that would cheer me up. If these are ‘up,’ I’d hate to see what
‘down’ is. As we continue to rummage
through your files, will we find material that is more encouraging?”
“No guarantee,
Julie. I suspect we’ll find lots
of suggestions of the right things to do, but examples of resounding successes
are apt to be rare. It will take a
lot more work before every hospital is as safe and efficient as a
nuclear-powered submarine and as customer-friendly as a Ritz-Carleton Hotel.”
Kaizen
Curmudgeon
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