I would like to open the discussion with one of my favorite books by Robert Wachter, "Internal Bleeding." He is a strong advocate of the system level fix philosophy and his book is a "must read" for anyone that can envision a global dedication to patient safety. He reinforces the idea that telling the nurse or the doctor to change their behavior is not enough. We have to demand that manufacturers of medical equipment work with our patient safety advocate groups to ensure that fail safes are built into their programs. For example, during a recent Root Cause Analysis involving an infant in which both the nurse and the doctor calculated the dose incorrectly, the team realized that the medication dispensing machine could be designed to prevent dosing errors... if it had required that the patient's weight be entered with the selected medication, the machine could be programed to calculate the appropriate dose prior to dispensing. Normal infant weight ranges would be included to identify inappropriate entries. This is a system level fix. It doesn't require human perfection.
OK... I want you all to be able to share your thoughts about "Internal Bleeding" as well. Please let me know what you thought.
1 comments:
Good review, Denise. It seems as if many patient safety events could be corrected by makers of patient devices and machines if they would move out of the "profit box" and into a true interaction and response to requests for improvement from users and buyers of their products.
NWW
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