Comments on: Just Throw Everyone in Jail, Then http://www.leanblog.org/2006/12/just-throw-everyone-in-jail-then/ Mark Graban's leanblog.org - Lean Healthcare, Lean Thinking, Lean Manufacturing, Toyota Production System Thu, 09 Feb 2012 22:59:58 +0000 hourly 1 http://wordpress.org/?v=3.3.1 By: Another Drug Error Waiting to Happen? — Lean Blog http://www.leanblog.org/2006/12/just-throw-everyone-in-jail-then/#comment-22730 Another Drug Error Waiting to Happen? — Lean Blog Thu, 28 Jul 2011 00:18:18 +0000 http://leanblog.bigbigdesign.net/2006/12/just-throw-everyone-in-jail-then/#comment-22730 [...] what is the root cause? In many cases, the caregiver is blamed and punished, leading to firing or even prosecution. But what about the drug maker and their role? What about the CEO of the drug maker, are they [...] [...] what is the root cause? In many cases, the caregiver is blamed and punished, leading to firing or even prosecution. But what about the drug maker and their role? What about the CEO of the drug maker, are they [...]

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]]> By: Let’s Sign Documents Promising Not to Make Errors? — Lean Blog http://www.leanblog.org/2006/12/just-throw-everyone-in-jail-then/#comment-13983 Let’s Sign Documents Promising Not to Make Errors? — Lean Blog Wed, 10 Nov 2010 10:04:10 +0000 http://leanblog.bigbigdesign.net/2006/12/just-throw-everyone-in-jail-then/#comment-13983 [...] A Wisconsin nurse jailed for a medication error [...] [...] A Wisconsin nurse jailed for a medication error [...]

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]]> By: Liveblogging the Quaid Patient Safety Documentary — Lean Blog http://www.leanblog.org/2006/12/just-throw-everyone-in-jail-then/#comment-9580 Liveblogging the Quaid Patient Safety Documentary — Lean Blog Sat, 24 Apr 2010 14:27:31 +0000 http://leanblog.bigbigdesign.net/2006/12/just-throw-everyone-in-jail-then/#comment-9580 [...] of those criminalized nurses (Julie Thao, who I blogged about here) tells her story: she had been working a double shift, it was almost 1 am. She had to be back later [...] [...] of those criminalized nurses (Julie Thao, who I blogged about here) tells her story: she had been working a double shift, it was almost 1 am. She had to be back later [...]

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]]> By: katmarie http://www.leanblog.org/2006/12/just-throw-everyone-in-jail-then/#comment-9434 katmarie Wed, 07 Apr 2010 04:18:15 +0000 http://leanblog.bigbigdesign.net/2006/12/just-throw-everyone-in-jail-then/#comment-9434 Everyone's blaming the nurse and yes she was negligent. She did not intend to harm anyone though. The fact that she is being treated as a criminal is preposterous! To all who are pointing a finger at this woman, Remember Jesus words. "He who is without sin, cast the first stone". No one is exempt from making mistakes in this life unless you are God or you are dead. Human beings make mistakes. In this case, the hospital's system was flawed. Why aren't the administrators being charged criminally? They are just as guilty as this nurse. Personally, if I was her, I would turn around and file charges against the hospital for unsound working conditions. Her life is ruined and all because the hospital like most hospitals wants to make an extra buck. I know this to be true because I have been there. I am a nurse and I wouldn't work in a hospital if you paid me a million dollars!!!!! Hospitals are not nurse or patient friendly. They expect you to hurry and sacrifice safety for getting more work done. The patient load is too much now. Patients are sicker and require more attention. The administration is clueless about what goes on at the bedside. No wonder nurses are getting out of the field. I am a school nurse and if it ever comes down to me having to go back to work in a hospital, I will leave the field of nursing. Everyone’s blaming the nurse and yes she was negligent. She did not intend to harm anyone though. The fact that she is being treated as a criminal is preposterous! To all who are pointing a finger at this woman, Remember Jesus words. “He who is without sin, cast the first stone”. No one is exempt from making mistakes in this life unless you are God or you are dead. Human beings make mistakes. In this case, the hospital’s system was flawed. Why aren’t the administrators being charged criminally? They are just as guilty as this nurse. Personally, if I was her, I would turn around and file charges against the hospital for unsound working conditions. Her life is ruined and all because the hospital like most hospitals wants to make an extra buck. I know this to be true because I have been there. I am a nurse and I wouldn’t work in a hospital if you paid me a million dollars!!!!! Hospitals are not nurse or patient friendly. They expect you to hurry and sacrifice safety for getting more work done. The patient load is too much now. Patients are sicker and require more attention. The administration is clueless about what goes on at the bedside. No wonder nurses are getting out of the field. I am a school nurse and if it ever comes down to me having to go back to work in a hospital, I will leave the field of nursing.

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]]> By: A Pharmacist’s Jail Cell Interview – What Good Does Blame Do? — Lean Blog http://www.leanblog.org/2006/12/just-throw-everyone-in-jail-then/#comment-8926 A Pharmacist’s Jail Cell Interview – What Good Does Blame Do? — Lean Blog Wed, 10 Mar 2010 09:02:21 +0000 http://leanblog.bigbigdesign.net/2006/12/just-throw-everyone-in-jail-then/#comment-8926 [...] might also remember this case I blogged about, in 2006, where an error a Wisconsin nurse was involved in was criminalized. Again, does that really [...] [...] might also remember this case I blogged about, in 2006, where an error a Wisconsin nurse was involved in was criminalized. Again, does that really [...]

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]]> By: Anonymous http://www.leanblog.org/2006/12/just-throw-everyone-in-jail-then/#comment-1346 Anonymous Tue, 12 Dec 2006 14:09:00 +0000 http://leanblog.bigbigdesign.net/2006/12/just-throw-everyone-in-jail-then/#comment-1346 kill the lawyers! kill the lawyers!

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]]> By: Anonymous http://www.leanblog.org/2006/12/just-throw-everyone-in-jail-then/#comment-1344 Anonymous Tue, 12 Dec 2006 13:25:00 +0000 http://leanblog.bigbigdesign.net/2006/12/just-throw-everyone-in-jail-then/#comment-1344 Until hospitals and lawyers understand that improvement should result from mistakes and not lawsuits the system may be doomed to continue as it is now. Lawyers are readily waiting for the big payoffs from the lawsuits and hospitals are protecting themselves by never admitting they made a mistake. Like the alcoholic the first step to recovery is to admit you have aproblem. Until hospitals and lawyers understand that improvement should result from mistakes and not lawsuits the system may be doomed to continue as it is now. Lawyers are readily waiting for the big payoffs from the lawsuits and hospitals are protecting themselves by never admitting they made a mistake. Like the alcoholic the first step to recovery is to admit you have aproblem.

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]]> By: Jamie Flinchbaugh http://www.leanblog.org/2006/12/just-throw-everyone-in-jail-then/#comment-1342 Jamie Flinchbaugh Tue, 12 Dec 2006 12:01:00 +0000 http://leanblog.bigbigdesign.net/2006/12/just-throw-everyone-in-jail-then/#comment-1342 This is a major problem. Base jumping (jumping off a building or bridge with a parachute) is statistically safer than going to the hospital. The error rate is astounding. The fact is this: over 90% of the work done in a hospital is what you would consider a "work around." We all do it - there is a way it should be done, and the way it actually gets done because the "should" isn't working for us. Most of it is done not because of laziness or irresponsibility, it is done because people try to do the right thing, but making things worse in the long-run. Work-arounds are everywhere - important info conveyed on post-its, backup storage of key meds because the main supply isn't accessible, little codes to shortcut writing it down everywhere - for most of us it's just less effective, but in hospitals we are killing people every day. I for one am scared white every time I go into a hospital. This is a major problem. Base jumping (jumping off a building or bridge with a parachute) is statistically safer than going to the hospital. The error rate is astounding. The fact is this: over 90% of the work done in a hospital is what you would consider a “work around.” We all do it – there is a way it should be done, and the way it actually gets done because the “should” isn’t working for us. Most of it is done not because of laziness or irresponsibility, it is done because people try to do the right thing, but making things worse in the long-run. Work-arounds are everywhere – important info conveyed on post-its, backup storage of key meds because the main supply isn’t accessible, little codes to shortcut writing it down everywhere – for most of us it’s just less effective, but in hospitals we are killing people every day. I for one am scared white every time I go into a hospital.

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]]> By: Mark Graban http://www.leanblog.org/2006/12/just-throw-everyone-in-jail-then/#comment-1339 Mark Graban Mon, 11 Dec 2006 19:14:00 +0000 http://leanblog.bigbigdesign.net/2006/12/just-throw-everyone-in-jail-then/#comment-1339 I do agree that the nurse has responsibility. I don't think it should be criminal. I agree that there should have been proactive processes and error proofing in place and that was administration's responsibility. If by "happen to any of us" it means ALL nurses circumvent procedures, then that is also the responsibility of administration. Why not throw the hospital CEO in jail then? Every hospital in America should be evaluating their procedures to see if that kind of stuff is happening, because I bet it is.<br/><br/>When one plane crashes at one airport, the aviation industry has a much better system for driving change and consistent processes to ALL airports, or so it seems. I do agree that the nurse has responsibility. I don’t think it should be criminal. I agree that there should have been proactive processes and error proofing in place and that was administration’s responsibility. If by “happen to any of us” it means ALL nurses circumvent procedures, then that is also the responsibility of administration. Why not throw the hospital CEO in jail then? Every hospital in America should be evaluating their procedures to see if that kind of stuff is happening, because I bet it is.

When one plane crashes at one airport, the aviation industry has a much better system for driving change and consistent processes to ALL airports, or so it seems.

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]]> By: Anonymous http://www.leanblog.org/2006/12/just-throw-everyone-in-jail-then/#comment-1338 Anonymous Mon, 11 Dec 2006 18:46:00 +0000 http://leanblog.bigbigdesign.net/2006/12/just-throw-everyone-in-jail-then/#comment-1338 I don't blame her for being <i>overworked</i> and <i>the victim of an inefficient process</i>, but she IS responsible for circumventing practices specifically designed to prevent something like this. If anything, the process should have been modified with MORE checks to prevent her from <b>"retrieving the epidural from a locked storage unit without a doctor's order, failing to scan the medication in a computer system that would have detected the mix-up, and ignoring large warning labels on the epidural."</b> Where do <i>you</i> draw the line between poka-yoke and efficiency? Shouldn't we sacrifice some of this "I need it now" mentality to make a hospital procedure error-proof? I would lose it if the hospital told me "There are many nurses who would say that could happen to any of us." YOU?!? WHAT ABOUT MY DEAD WIFE!?! I don’t blame her for being overworked and the victim of an inefficient process, but she IS responsible for circumventing practices specifically designed to prevent something like this. If anything, the process should have been modified with MORE checks to prevent her from “retrieving the epidural from a locked storage unit without a doctor’s order, failing to scan the medication in a computer system that would have detected the mix-up, and ignoring large warning labels on the epidural.” Where do you draw the line between poka-yoke and efficiency? Shouldn’t we sacrifice some of this “I need it now” mentality to make a hospital procedure error-proof? I would lose it if the hospital told me “There are many nurses who would say that could happen to any of us.” YOU?!? WHAT ABOUT MY DEAD WIFE!?!

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