Medical Errors Report #13

A Four-Year Solution Implementation Study

Lack of Conducive Atmosphere Impedes Solution Implementation

Although many hospital administrations want to fix medical errors, they have not created an atmosphere conducive to allowing it to happen. In some situations, some administrations have created barriers of their own to fixing medical errors or systemic failure. Certain conditions need to be created by the establishment to ensure that project masters are not persecuted by their departments, that supervisors and frontline workers must work together for progress. This will not happen when the head of a department or a supervisor continues to attack the project master due to philosophical disagreements. There have been situations where both the director of a department and the supervisors opposed a quality improvement project initiated by the hospital administration. Either lack of awareness of the problem or the inability of the hospital administration to fix the problem places the project master on direct-line of attack and criticism from his department. One constant complaint of quality improvement officers is the lack of support from the hospital administration. In the case just mentioned, a detached hospital administration could not see the crisis and ended up blaming the project master. By the time the administration was aware of what was happening, it was too late.

 Tapping into the Knowledge Base of Older and Experienced Employees Can be Helpful to Process Improvement

For younger supervisors managing an older and more experienced staff can be a challenge. Younger managers tend to respond with more emotions to issues and incidents. They should be very careful. Instead of fighting older workers with long years of experience, the supervisor must tap into the wealth of these workers’ knowledge. There is no need to yell at them just because some of them may be earning more money due to their long years of service. Those experienced workers have been responsible for saving patients’ lives by preventing systemic failures before they happen. Being a supervisor does not make you superior to your coworkers. Inexperienced managers often make this type of mistake leading to chaos and discontentment in the department. This reminded me of an institution where supervisors would politely request other employees to do things not included in their job definition. However, one short-stature blood bank supervisor used to throw folders at a man old enough to be her uncle saying, ”File those folders.” The older employees felt insulted. Other employees who witnessed the insulting behavior indicated that, apart from her arrogance, she was able to get away with insulting the older employee because he is a minority. Insulted employees are not excited about reporting systemic failures, they just ignore them and walk away.

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