Not directly stroke related but it should be. The unattainable goal of 100% recovery for all will never occur under current stroke leadership. They all need to die. Too bad. They had their chance and totally blew it, don't feel sorry for them.
The Necessity of Striving for Unattainable Goals
We can't eliminate all errors. But we have to keep trying
Walking into the office very early this morning, before the 8:00 seminar I was scheduled to give for the interns on ambulatory block rotation, I happened to look up and notice this safety cone, which stays curled up in a gray plastic container on the wall of our practice, right where it has been for quite a few years.It is one of those "In the Event of a Spill" devices, an intervention that is supposed to protect our staff and our patients from trips and falls should liquid spills end up in the hallways of our practice.
Pull down and it pops open, a little hazard-yellow tripod, meant to stand guard and protect.
They're scattered at various points throughout the practice, tucked up in the corner on the walls, available should anyone notice anything spilled on the floor, be it water, coffee, urine, vomit, blood, or pretty much any other fluid one might encounter in a medical practice. It's meant to be a temporary thing, a warning, a "watch your step", something to tide us over until the appropriate cleanup can occur.
Now obviously, when I spill a cup of water, instead of putting a cone on it marking it as a potential hazard, I should probably just grab some paper towels and wipe it up.
But if a chemical hazard spill occurs, or a body fluid that needs safer and more effective cleanup, it makes sense that we warn patients and staff not to step in it, while we wait for appropriately armed personnel to arrive to safely eradicate the problem.
Unfortunately, this reminds me a little bit of institutional quality and patient safety efforts.
Across healthcare institutions, including our own, there are multiple committees and groups that get together to review quality improvement efforts and patient safety efforts, tracking errors in the practice, focusing on efforts to prevent, improve, and correct these by getting to the heart of the matter.
Every year, each practice is required to present, to each of these committees, a compilation of our quality improvement and patient safety efforts throughout the past year.
This includes a description of our practice and leadership structure (as if they do not already know who we are), and a compilation of the quality and patient safety team showing how reporting is done, essentially who does what, and then a long list of things that have been noted and responded to over the past year.
We have an electronic system in which safety issues can be reported, for errors and near-harm events, including such things as falls, mislabeled specimens, and other bad outcomes.
We have another system that collects patient complaints and grievances, which come to our practice from multiple sources, including individual providers, our administrators, and Patient Services.
And then we have a long list of projects we have done, things we have been working on over the past year meant to improve our performance on measures that we have either deemed important to our practice, areas where we have been found lacking, processes that have been analyzed and found to be fraught with errors or risk thereof, and regulatory requirements that necessitate the collection of data and the implementation of further practice improvement.
We also have extensive quality improvement education and curriculum within our practice, for the faculty and residents and medical students, which has in-itself led to quite a few successful projects that improve the way we take care of patients.
Those doing the work and seeing the errors are often best in a place to figure out a better way to do things. And sometimes you need a fresh pair of eyes to move us away from "we do it this way since this is how we have always done it".
But as our systems continue to evolve, I hope we move away from the collecting of data in all these small incremental steps aimed at improving quality and safety.
We're never going to be 100% error-free.
In a practice where we have many patients with many significant comorbidities, and gravity is in play, people are going to fall.
We have a water cooler in our waiting room, there will be spills.
Three to four hundred patients make their way through so many different interactions when they visit our practice, from registration to medical technician to provider to nurse to phlebotomist means nearly overwhelming opportunities to miss something or trip up on some minor detail.
But our staff has done an incredible job of identifying many of these problems, both environmental and structural, within our practice, as well as with the procedures we do and how we handle our patients, which have led to significant interventions to prevent slips, falls, and medical errors from happening.
One would think that in the 21st-century that it would be impossible to draw a patient's blood into a tube labeled with someone else's medical record number, but it happens.
Surgeons sign their sites, not because anyone thinks they are just operating willy-nilly, but because it is a chaotic storm of stuff we are working in, and we all need all the help we can get.
We can have endless meetings and endless discussions about what works in the airline industry or what worked for Toyota long ago, but as long as there are humans involved, there will always be errors.
I can only hope that as we continue to evolve and improve these processes, we're not just putting up a pop-up cone over a spill, and hoping no one slips and falls.
So we'll keep going to meetings, we'll keep reporting, we'll keep participating in all of these quality improvement and patient safety initiatives, but we need to make sure it's not just lip-service. Everyone needs to be fully engaged and the people in power need to make sure that we all have all the tools we need, that we're not rushed, that we're not burned-out, that we always treat each of our patients exactly as we would want one of our own family members to be treated.
When we do that, quality will improve, and patients will be safer, to the limits which we are able to get them to.
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