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When Things Go Wrong, Admit Mistakes

Joe Cantlupe, for HealthLeaders Media, October 13, 2011

Indeed, UIMC's communication style that was on display with the Malizzos was formed in its patient safety program that allows nurses, physicians, and administrative staff to move quickly to report, review, and effect change following patient safety errors, McDonald says.

Since 2006, the hospital has established a protocol known as the Seven Pillars: Crossing the Patient Safety Medical Liability Chasm.

Last year, UIMC received a $3 million federal grant for the program as a demonstration project.  The program objectives, as outlined by McDonald, are to "improve patient safety and mitigate medical liability risk through improved communication with patients and family, disclosure and early (monetary) offer when patients suffer preventable harm, and learning from mistakes to prevent future harms."

When UIMC began reporting on unsafe conditions, and harmful events, staff reported about 1,500 occurrences the first year – a number that seemed "highly" inaccurate, McDonald says. However, staff "spread the word that leadership was behind this" reporting initiative. Now, there are about 8,000 such events reported annually, McDonald says.

"To some extent, we know everybody's worried about getting sued," he said. "But if you take a principled approach to harm, you can avoid a whole lot of lawsuits, and come to appropriate non-adversarial resolutions. In a whole lot of our cases, we've avoided protracted litigation that brings docs in and everything else."

McDonald says UIMC "embraces the concept of collective accountability" when appropriate and "reaches out to the family for quicker resolution before they decide to go to trial."

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1 comments on "When Things Go Wrong, Admit Mistakes"


David Joyce MD MBA (10/13/2011 at 4:37 PM)
So let's hear about the bottom up continuous process improvement initiative that they have developed and how it has reduced errors. It is likely that there is none. Did having an anesthesia fix a problem, how prevalent was the problem, what was the root cause? They have a great committee to communicate when there is a problem but I would bet there isn't a single process improvement project led by those actually doing the work. Why, those who do the work do not have the business skills to improve.