{"id":26,"date":"2009-07-10T11:08:24","date_gmt":"2009-07-10T15:08:24","guid":{"rendered":"http:\/\/qimacros.com\/lean-six-sigma-blog\/?p=26"},"modified":"2015-02-12T22:07:17","modified_gmt":"2015-02-12T22:07:17","slug":"surgical-hospital-shut-down","status":"publish","type":"post","link":"https:\/\/www.qimacros.com\/lean-six-sigma-blog\/surgical-hospital-shut-down\/","title":{"rendered":"Surgical Hospital Shut Down"},"content":{"rendered":"<p>The Denver Post reported that the Colorado Orthopaedic and Surgical Hospital was shut down this week after a patient&#8217;s death. What went wrong?<\/p>\n<ul>\n<li>Patient was given a a pain killer in too high a dose.<\/li>\n<li>Patient was left alone for 15 minutes after receiving the drug.<\/li>\n<li>Staff was unfamiliar with the crash cart.<\/li>\n<li>The rapid reponse team had trouble reaching the patient&#8217;s room.<\/li>\n<\/ul>\n<p>The nurse involved resigned.<br \/>\nWhat did the hospital pledge to do? Increase training on emergency response.<\/p>\n<p>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&#8217;t use it in 72 hours after training.)<\/p>\n<p>This illustrates another common mistake: managers want to accelerate the &#8220;fix-it&#8221; process. Without the overdose, would they have needed emergency response?<\/p>\n<p>How could they mistake-proof the process so that it is <em>impossible<\/em> to give too high a dose of <em>anything<\/em> via the method of delivery. I&#8217;m guessing this dose was given intravenously rather than orally.<\/p>\n<p>A few years back there was a Dateline story about a boy who died from an <em>injection<\/em> of a <em>topical<\/em> anesthetic. Shouldn&#8217;t there be a way to mistake-proof the delivery of substances?<\/p>\n<p>Why is the cost of healthcare so high? Too many preventable mistakes.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>The Denver Post reported that the Colorado Orthopaedic and Surgical Hospital was shut down this week after a patient&rsquo;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 [&hellip;]<\/p>\n","protected":false},"author":4,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[6,7],"tags":[48,170],"class_list":["post-26","post","type-post","status-publish","format-standard","hentry","category-service","category-six-sigma","tag-insights-tagged-as-healthcare","tag-six-sigma"],"_links":{"self":[{"href":"https:\/\/www.qimacros.com\/lean-six-sigma-blog\/wp-json\/wp\/v2\/posts\/26","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.qimacros.com\/lean-six-sigma-blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.qimacros.com\/lean-six-sigma-blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.qimacros.com\/lean-six-sigma-blog\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/www.qimacros.com\/lean-six-sigma-blog\/wp-json\/wp\/v2\/comments?post=26"}],"version-history":[{"count":1,"href":"https:\/\/www.qimacros.com\/lean-six-sigma-blog\/wp-json\/wp\/v2\/posts\/26\/revisions"}],"predecessor-version":[{"id":557,"href":"https:\/\/www.qimacros.com\/lean-six-sigma-blog\/wp-json\/wp\/v2\/posts\/26\/revisions\/557"}],"wp:attachment":[{"href":"https:\/\/www.qimacros.com\/lean-six-sigma-blog\/wp-json\/wp\/v2\/media?parent=26"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.qimacros.com\/lean-six-sigma-blog\/wp-json\/wp\/v2\/categories?post=26"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.qimacros.com\/lean-six-sigma-blog\/wp-json\/wp\/v2\/tags?post=26"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}