Continously Strengthening Patient Safety ProceduresPaul Levy, the President and CEO of Beth Israel Deaconess Medical Center in Boston, maintains a blog he calls "Running a Hospital." One of today's posts reproduces a write-up by two employees describing how overdosing a patient was avoided, and further, how the root cause of the near overdose was identified and corrected.
As you can see from reading the post, Beth Israel extracted two main lessons from the near-miss:
- Even though an automated medication dispensing machine reduces the risk of mistakes in administering meds, it is still necessary for a human being at the bedside to doublecheck that the medication picked by the machine is correct.
- When a near-miss occurs, all interested parties must be notified so that unwitting repetition of the problem is forestalled. Beth Israel has a safety reporting system into which personnel are expected to enter the details of all adverse incidents. Those monitoring the incidents can then see any trends that suggest a systematic weakness that needs to be fixed.
PS. You can watch a video to hear Levy talking at a 2007 conference in the Netherlands about how to run a hospital, how to use new media, and reasons for an executive to blog.