One thought on “Hospital Errors Persist, State Probes Rare

  1. As long as conflicts of interest and obsolete technology for communications and care coordination remain the norm, all efforts to reduce errors will continue to fail – they will miss the most important contributors.  In addition, the current overwhelming focus remains on individual cases and individual care giver causes (systems issues get much lip service and little else), with inefficient and labor-intensive tracking tools, trainings, etc. all distracting and taking time & energy away from bedside time.  Such efforts seem more likely to increase errors than decrease them, as they miss the mark, and add to the burdens on Nurses while costing them precious time.  Do not doubt it, generally all such tasks are added to Nurses’ workload while no time is added, and no other responsibilities subtracted.  Added pressure, added demands, with less time (as time is taken from care): an obvious recipe to increase errors, sad and ironic when offered in the name of the opposite. 
    We desperately need to focus less on individual cases – a hopelessly inefficient approach: this article shows much time spent on reporting, tracking, tracking the reporting, reporting the tracking, analyzing all the above, leaving a minority of cases actually investigated at all.  We need instead to start tracking systems and their results: inventory management, communications, coordination – in the same way the airline companies have long done, with far superior results than any in health care, and far less cost to achieve it.  We need to explore ways to improve efficiency and clarity and actually improve things, instead of all the current wringing of hands, paper shuffling, and reports as to how, yet again, our results remain mixed at best, backward at worst.  Our current approach to error is itself erroneous and obsolete.

    It has been said (John Dryden?) that the definition of insanity is trying the same approach, over and over, and expecting different results.

    When, in health care regulation and practice, will we finally, at long last, stop the insanity?

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