Recently a colleague's quest to get a copy of an article while encountering erroneous automated responses regarding its free access illustrated one type of failure that can plague health care and potentially affect patient care.
What if this instance had been connected with a direct patient care emergency? What if it had been a clinician trying to find something after hours, just didn't have the time to figure out why access was denied, or didn't have colleagues (like other information providers) that would get him/her what they needed quickly?
Might I suggest that it would be an informative exercise to do a bit of proactive analysis of this type of situation to see what might be learned from it and teach our organizations about failures in the line of information access / knowledge transfer.
I've been working with colleagues at the VA's National Center for Patient Safety to develop a use of the
failure modes and effects analysis model
to help medicine understand these types of problems. But -- in the quest for safer patient care -- others should explore them as well. Please share your stories with us here.
Surgical fires: decreasing incidence relies on continued prevention efforts. - Bruley ME, Arnold TV, Finley E, Deutsch ES, Treadwell JR. PA-PSRS Pa Patient Saf Advis. June 2018;15.
2 days ago