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When Things Go Wrong, Admit Mistakes
The University of Illinois Medical Center has a protocol for adverse events that occur when the hospital staff is at fault: Admit your mistakes and avoid malpractice litigation.
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.