September 24, 2018 | Mark Paradies

Monday Accident & Lessons Learned: HOW MANY INCIDENTS DOES IT TAKE TO LEARN???

Is it acceptable to have incidents occur over and over again?

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The Daily Mail (a UK paper), ran an article about repeat incidents at a UK hospital (pictured below).

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This first was a hospital acquired infection that caused a patient to sue and win a six figure payout. I’ll let you read the article to find out what essential part of his anatomy that he lost.

That settlement had just been negotiated when a second patient had the wrong testicle operated on. And a third patient had a lesion removed from the wrong brest.

The Daily Mail reported that the hospital spokesperson claimed:

“Southend University Hospital continues to be compliant with the national recommendations
on learning from deaths through better engagement with bereaved families and carers,
strengthened governance arrangements for mortality monitoring by newly introduced
medical examiner roles and increased transparency.”

It would sure make me a more confident patient if the performed advanced root cause analysis and implemented corrective actions to STOP repeat incidents rather than having repeat incidents and “continuing to learn.”

They also said:

We are pleased our mortality indicator score has consistently decreased since
June 2017 and is now within the expected range for the first time since June 2015
.”

Stopping killing patients is a great idea. I’d suggest a better goal. STOP sentinel events including ALL never events.

Investigating never events and learning isn’t enough to make this happen. Hospitals need to become proactive in their improvement programs.

Are you interested in advanced root cause analysis and becoming proactive in your improvement program?

I would suggest attending a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. We hold them around the world … including Europe. See the upcoming courses held around the world by CLICKING HERE.

Want to learn more about proactive improvement? Attend the 2019 Global TapRooT® Summit in Houston, TX. Learn from industry leaders from around the world how they proactively solve problems. get more Summit info HERE.

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