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I think it might be useful for us to abstract ourselves from the details of this case and think about the situation in general terms.

In any system as carefully choreographed as health care, and in my work, a health information system, it only makes sense that every actor has a role in making it safer. This is what the Toyota Motor Company has done throughout its history, and what we implemented in our care institution.

We found that it was important that the Medical Director of Informatics be aware of all potential safety threats. But that is not enough. Every patient, nurse, and physician must also be aware. And when they believe there is a problem, it is taken seriously. By taking seriously, we mean a scripted answer to every query that is something along the lines of, “Patient safety is very important. How can I help?” A staff member or patient should never feel uncomfortable in bringing problems forward.

What Toyota did is apply a democratic process to discovering errors, and I have found this works very well in health care, when we step back and think about it from our patients’ perspective.

We wrote about this in our blog on LEAN in Health Care about a year ago:

http://www.dailykaizen.org/archives/236

Unfortunately, the first time something happens in a health care situation can often be one time too many, so even the potential of it happening must be seen as discovered gold, not something to be buried.

Our patients want to be our partners in supporting a safe health care system. Being a partner means that they have all of the information that we do.

Thank you for bringing up this important issue.

Best regards,
Ted Eytan, MD

——
e-Patient Dave