Case Memo
Please read "Children's Hospital and Clinics (A)" available in the course packet and consider the following questions:
1) What is your assessment of the Patient Safety Initiative at Children's? What do you think about blameless reporting? Answer: blameless reporting：Blameless reporting encouraged front line workers to use patient safety reports to discover and eliminate breakdowns in hospital systems and processes. Language 好处：Indeed, Morath emphasized the avoidance of several words that were indicative of a culture where people “pointed fingers” at others, rather than trying to learn from mistakes and failures. 问题和担忧关于BR：However, not everyone was enthusiastic about this new approach. Several employees expressed concern about the inability to reprimand individuals involved in such events. Some unit managers wondered how they could hold people accountable if they were not able to discipline people for making mistakes. Moreover, some members of the professional staff still believed that many errors occurred due to incompetence rather than failed systems. They worried that blameless reporting might make it more difficult to identify poor performers in their units.
2) What barrier(s) did Morath face as she tried to encourage people to discuss medical errors more openly? How did she overcome those barriers? Answer: It is difficult to broach the topic of safety because most people get defensive. Talking about safety implies that we are doing things “wrong.” Hospital employees feared that starting a discussion about medical accidents would alarm families, and perhaps might imply that the hospital was not safe. Morath found that many people initially were reluctant to believe that errors might be a significant problem at Children’s.
How: As part of my entry into the organization, I had carefully crafted conversations around the topic of safety with people who would have to be on board with the initiative. I did spade work, talking about how we could align the whole
1) What is your assessment of the Patient Safety Initiative at Children's? What do you think about blameless reporting? Answer: blameless reporting：Blameless reporting encouraged front line workers to use patient safety reports to discover and eliminate breakdowns in hospital systems and processes. Language 好处：Indeed, Morath emphasized the avoidance of several words that were indicative of a culture where people “pointed fingers” at others, rather than trying to learn from mistakes and failures. 问题和担忧关于BR：However, not everyone was enthusiastic about this new approach. Several employees expressed concern about the inability to reprimand individuals involved in such events. Some unit managers wondered how they could hold people accountable if they were not able to discipline people for making mistakes. Moreover, some members of the professional staff still believed that many errors occurred due to incompetence rather than failed systems. They worried that blameless reporting might make it more difficult to identify poor performers in their units.
2) What barrier(s) did Morath face as she tried to encourage people to discuss medical errors more openly? How did she overcome those barriers? Answer: It is difficult to broach the topic of safety because most people get defensive. Talking about safety implies that we are doing things “wrong.” Hospital employees feared that starting a discussion about medical accidents would alarm families, and perhaps might imply that the hospital was not safe. Morath found that many people initially were reluctant to believe that errors might be a significant problem at Children’s.
How: As part of my entry into the organization, I had carefully crafted conversations around the topic of safety with people who would have to be on board with the initiative. I did spade work, talking about how we could align the whole