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Will We Ever See Zero?

Maureen Larkin, for HealthLeaders Media, February 21, 2008

A story about Medicare's looming deadline for "never events" traveled around the Associated Press wire earlier this week, informing the general public about what those of us who work every day in quality and infection control already know: As of October, Medicare has declared that it won't pay for certain hospital-acquired conditions and happenings and others--including state governments and private insurers--are following suit.

The article presents several examples of hospitals that are instituting new policies and procedures that will help their institutions avoid these "never events." At the University of Michigan Health System, the article says, surgeons are using sponges tagged with radio frequency identification (RFID) chips to make sure that a stray sponge doesn't get left in a patient during surgery. In Tennessee, Wellmont Hospital is using a portable machine that releases sterilizing vapors to help eliminate germs in patient rooms, the article says.

These examples--and the hundreds of others that my colleagues and I have written about--show what we already know: by examining their processes, hospitals have been able to improve their infection rates, prevent staff errors and other "never events." Sure, we can improve our statistics, but will we ever get to a point where there are no errors, no falls, and no infections? The reality is no. Only eternal optimists will tell you that someday we might have a healthcare system that provides care with zero chance of errors. Humans aren't perfect, and as long as humans are caring for humans there are bound to be mistakes. Still, Steven Gordon, MD, infectious disease chief at the Cleveland Clinic Foundation, tells the Associated Press that it isn't stopping hospitals from wanting to get to zero.

Some might question whether an unattainable goal has value. Much thought on leadership goes to the notion that goals should be realistic and manageable, and indeed at the hospital unit level, quality goals are meant to be measured and met. As an industry, reaching zero must continue to be the motivating goal behind the work we do at our hospitals. It should be the underlying message in our staff meetings, training sessions and quality improvement meetings. We must evaluate the steps we're taking to prevent infections, falls and errors and among our caregivers, stress the processes that will give us the best return on our investment. The questions coming in quality are not what gets us to zero, but what initiatives get us closer than the others.


Maureen Larkin is quality editor with HealthLeaders magazine. She can be reached at mlarkin@healthleadersmedia.com.

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