I am sure that many of you have heard the saying "What you do not know can not hurt you." From much experience I know that just is not true in many cases, especially in healthcare. Consider these cases if you will:
Because I am previously involved in alcohol and other drug research, I have the opportunity to hear many stories from recovering alcoholics. One story related directly to care this person was receiving for a persistent cough. The patient's doctor had prescribed cough syrup with codeine; the patient reported to fellows at an AA meeting that she wanted to drink it all at once. Clearly, the codeine appeared to her addictions. A doctor who had been aware of her past and who knows the problems with narcotic substances for recovering alcoholics would never have made this prescription.
Failure to know what medications a patient is taking account for many of the errors at hospitals. For instance, not knowing a male patient is on aspirin therapy can lead to complications during surgery. That is why JHACO is emphasizing reconciling medications at admission to hospitals.
I am sure that many of you are familiar with the "blame game" found in many medical settings. It goes something like this: "If only that person in the pharmacy would get the medicines to our staff on time there would not be any problems here!" I am sure many of you have thought of this in one setting or another. An April 2005 issue of "Quality Progress" detailed in "Lean Six Sigma Reduces Medication Errors" the anger between staff nurses and the in hospital pharmacy staff over the timely delivery of medicine. The ultimate issue in this story was that neither party understood the others' processes in the mediation routine.
The root of most of the problems listed above was failure in communication. Fortunately, the tools of quality improvement stress communication in many forms. One such tool is to standardize processes so that all follow the same basic process route. For instance, if primary care physicians incorporated screening for alcoholism in routine care, the errors related to addictive behavior could have been avoided. For instance, the typical form handed out to patients before physicals could certainly include the CAGE questions for alcohol screening, much as these questions include questions about tobacco use. The nurse checking blood pressure before the doctor comes in could ask "how many times have you had alcohol in the past two weeks and how much on each occasion?", Thus checking for abuse problems.
Leaders, including the CEO, at McLeod Regional Medical Center in South Carolina routiniously make morning rounds to check all areas of the hospital, including talking with patients and auxiliary personnel. Just by making contact with various personnel they are open up communication in the hospital, as well as becoming aware of various problems from many different points of view. By understanding problems from different viewpoints they are in a position to provide effective leadership in solving the problems. …