MEDICAL MALPRACTICE
and deviations from policy and best practice, and by poorly designed processes that invite error and mistakes (a checklist that's so routine, it becomes rote, for example). A risk-management program should focus on reducing human errors, such as over-reliance on memory, by using outcome-driven protocols and by simplifying ambiguous and complex processes. You should
heighten awareness of patient-safety concerns with communication and training. For example, we have a quarterly nursing "grand rounds" meeting in which we talk about incidents, how they happened, and what process changes we made as a result. We've found that staff members are more likely to buy into process improvements when they understand the rationale
behind them.
Remember that reward is more effective than punishment. "The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes," says Lucian Leape, MD, a professor at the Harvard School of Public Health and author of the seminal 1994 JAMA article, "Error in Medicine." Don't fall into that trap.
Dig deep with a root-cause analysis
We all know surgery's high-risk events: retained objects, wrong-site/wrong-procedure surgery, informed-consent issues, misidentification of the patient, inadequate preoperative evaluations, and anesthesia and medication errors. When these types of incidents occur, recognize potential liability and perform a root-cause analysis (RCA), not only to determine what happened and how to prevent a reoccurrence, but also to provide background information if litigation follows.
For an RCA to succeed, participants must know that the process
