Saturday, March 13, 2010

Hospitals Owning Up To Their Mistakes--It IS Possible

Some hospitals and CEO's get it--that when mistakes happen, full accountability and transparency is the only right choice. Two hospital CEO's recently recounted preventable medical mistakes that caused unnecessary deaths in their hospitals. One CEO candidly relayed how a preventable methicillin resistant staff infection (MRSA) spread through the hospital's neo-natal intensive care unit and sadly took the lives of possibly three infants:

That infection was part of a spread of a bug in his neo-natal intensive care unit that led to the colonization of 18 infants in all, and may have contributed to the death of two others. "This was a direct result of staff not washing their hands appropriately," he said. Since that event, "we have been on a relentless hand hygiene campaign."

The crux of his, and the entire presentation hinged on this comment: "My objective today is to confess," Wiles said. "I am accountable for those unnecessary deaths in the NICU. It is my responsibility to establish a culture of safety. I had inadvertently relinquished those duties" by focusing instead on the traditional set of executive duties (financial, planning, and such).

Wiles ended his talk to the CEOs in the audience, saying, "If you cannot see the face of your own relative in a patient, or if you can not see the face of your own son or daughter in the face of a distraught nurse or doctor who has made an error, I suggest that your executive talents would be better placed in other industries."

The other story from the second CEO is equally compelling. These gentlemen deserve credit and accolades for stepping to the plate, admitting medical errors when they occur, and making necessary changes.

Too often, here's what usually happens, in this order: there is a huge medical mistake, or the family knows enough to suspect one was made, inquiries are made, the family is shuffled around to various officials who "don't really know what happened" but who "will get back to you", etc. Bottom line: the family is left with no real answers as to what happened. When the dust settles and the family finally obtains the "official" medical records, it's analagous to a hunk of swiss cheese: lots of holes or gaps, in the form of a lack of information. Or worse yet, information or data that has been destroyed or is curiously "missing."

A culture of safety? The norm is a culture of outright denial after a medical event. The eventual lawsuit is filed, where the hospital is given an opportunity to admit responsibility, which is usually denied even when the mistake is relatively obvious. Some medical observers have argued that until hopsitals develop a culture of safety similar to the airline industry, preventable medical errors will continue to be prevalent. It is estimated that upwards of 100,000 patients die every year in hospitals due to preventable medical mistakes.

The candor of the CEO's is refreshing especially when compared to some for profit hospital chains where a "business model" of hospital acquisitions, "earnings per share," and EBITDA (earnings before interest, taxes, depreciation, and amortization)occupies a higher pecking order than a culture of patient safety.

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