Improvement Insights Blog
Surgical Hospital Shut Down
The Denver Post reported that the Colorado Orthopaedic and Surgical Hospital was shut down this week after a patient’s death. What went wrong?
- Patient was given a a pain killer in too high a dose.
- Patient was left alone for 15 minutes after receiving the drug.
- Staff was unfamiliar with the crash cart.
- The rapid reponse team had trouble reaching the patient’s room.
The nurse involved resigned.
What did the hospital pledge to do? Increase training on emergency response.
All too often, managers think that better training will lead to better results. Unfortunately, employees come and go. Training degrades over time (you lose 90% of what you learn if you don’t use it in 72 hours after training.)
This illustrates another common mistake: managers want to accelerate the “fix-it” process. Without the overdose, would they have needed emergency response?
How could they mistake-proof the process so that it is impossible to give too high a dose of anything via the method of delivery. I’m guessing this dose was given intravenously rather than orally.
A few years back there was a Dateline story about a boy who died from an injection of a topical anesthetic. Shouldn’t there be a way to mistake-proof the delivery of substances?
Why is the cost of healthcare so high? Too many preventable mistakes.
