Holiday Blog Break

2

I'll be mostly away from the blog through January 2nd. Happy Holidays to all of you… here's a little photo treat from one of my hospital colleagues. All the Type A's were hung by the patient with care? :-)

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Mark Graban is an internationally-recognized consultant, author, and professional speaker who has worked in healthcare, manufacturing, and startups. His latest book is Measures of Success: React Less, Lead Better, Improve More. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. He also published the anthology Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also a Senior Advisor to the technology company KaiNexus.

2 Comments
  1. Anonymous says

    Hello

    Well, while you are on holidays, Hospital not-Lean management is making big headlines here in France.
    url
    http://www.leparisien.fr/faits-divers/mort-d-ilyes-a-l-hopital-le-flacon-n-etait-pas-a-sa-place-25-12-2008-353629.php

    Short passage translation:
    “According to a source, both bottles were extremely similarly looking, with same cap and same blue label even if label text, B46 for one and magnesium chloride for the other, were different.”

  2. Mark Graban says

    Here is a google translation from French to English:

    LINK

    Part of the translation:

    “The nurse has admitted to mistakenly given the child an infusion of magnesium chloride instead of glucose intended to rehydrate. This misunderstanding might have caused a cardiac arrest of the child who had been hospitalized for angina.

    The nurse, aged 35, was under investigation Friday for “involuntary homicide” and placed under judicial control. It was referred to in the afternoon at the public health division of the Paris court where the judge Marie-Odile Bertella-Geffroy has held against him “a simple negligence, recklessness or carelessness.” “

    As I’ve written about before, I’m not a big fan of filing criminal charges against an individual for what’s most likely a process problem. What responsibility did hospital management and leadership have to make sure processes were error proofed so the wrong med can’t be given to the wrong patient?

    We need to focus on prevention and learning, not punishment.

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