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Never events. Well, hardly ever.: Thoughts about Hospitals, Medicine and Health Care Issues
by Paul Levy - September 7, 2011   Bookmark and Share
Provided by Not Running a Hospital

Many thanks to Ishani Ganguli for inviting me to write an op-ed inVirtual Mentor, the journal she guest-edited for the American Medical Association.  In it, I discuss the persistent rate of wrong-site surgeries and argue that financial penalties for such "never events" are ineffective:
 
In the face of slow progress, there is little doubt why the regulatory hammer is employed. But it is a crude tool. Its effectiveness as a deterrent is minimal because it does not address the structural issues underlying the problem. It emphasizes a particular outcome rather than a process that will achieve it. It penalizes people when it is too late to make a difference. Finally, it serves mainly to create resentment among those who are targets for improvement. Such is often the nature of regulation, no matter how well intended.
 
I argue, instead, for the power of training in crew resource management and transparency. 

Transparency, combined with a commitment to and training in crew resource management, enables doctors to hold themselves accountable to the standard of care they would wish for their own family members. This combination of ingredients offers far more potential than financial penalties or other regulatory actions for sustained process improvement in the operating rooms of America.
 
The entire article is here.   I welcome your comments.

Paul Levy is the former CEO of a large Boston hospital. He blogs to share thoughts about hospitals, medicine, and health care issues. Paul is an advocate for patient-driven care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement.


The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
 

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