Unlike my former hospital, we're not willing to lose information about system breakdowns, holes in the medication administration process, staffing, environment, safety, orientation processes, competency, communication, technological support, and other factors that contribute to errors. We try to provide a supportive environment for physicians, nurses, pharmacists, and others to report errors and significant near-misses. Our goals are to get to the bottom line and improve the process. In 1999, the facility generated 32,599 inpatient days and 209,711 outpatient visits. We realize that medical mistakes are seldom the result of a single error.
Broken processes contribute heavily to the problems.
We learn about systems or process inadequacies through individual errors, then fix the processes. A group meets each week to review errors and perceived errors. The group, which includes a physician chair, an attorney, two RNs, a human resource specialist, a paralegal, and administrative representatives, handles most individual issues immediately. Physicians and nurses are involved throughout the evaluation process. We encourage them to provide information and honest clinical evaluation.