Hospitals are busy, complex organizations. This unfortunate incident reminds us again that to err is human, and checklists and protocols are a critical error-stopping tool.
Collierville, TN (PRWEB) February 05, 2014
In Richmond, Texas, Jessica Escobedo gave birth to a baby girl. The new mother then experienced a nightmare when her one-day-old baby was breastfed by another woman due to a hospital mistake. Ms. Escobedo was also given the wrong baby during feeding time. Jessica caught the mistake when the name band on the child she was given did not match her own. Alarmed, she asked the nurse where her baby was. Unfortunately, her daughter had been taken to, and already breastfed by, the wrong mother.
The Chief Medical Officer at the hospital blamed the error on the failure “…to follow protocol which was checking both bands- one on the baby, one on the mother.” Officials with the hospital issued an apology to the parents and confirmed the mistake. The mother who nursed the baby was tested for diseases including HIV and all tests were negative. The nurse responsible for the error was fired.
“This sort of medical error is not all that unusual,” says Steve Harden, CEO of LifeWings-a patient safety consulting firm. “A recent study published in the Journal of Patient Safety says that between 210,000 and 440,000 patients each year who go to the hospital for care suffer some type of preventable harm. Hospitals are busy, complex organizations. This unfortunate incident reminds us again that to err is human, and checklists and protocols are a critical error-stopping tool.” “
Commenting on this incident, Mr. Harden pointed to the importance of recruiting patients to become part of the safety team. “Had this hospital made it a practice to ask patients to cross-check the arm band of their child every time it was brought in the room, both mothers would have done what Jessica did and this mistake never would have happened. Patients will never be as safe as possible if they don’t take an active part in the care they receive. It is the responsibility of the hospital to help them play this role.”
LifeWings, a team of physicians, nurses, pilots, and astronauts, specializes in TeamSTEPPS training and checklist development to prevent medical mistakes. TeamSTEPPS is a patient safety training developed by the Department of Defense Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality (AHRQ). The patient safety program has a proven track record of reducing medical errors and improving patient outcomes.
These essential mistake-stopping techniques and protocols have been implemented by LifeWings in over 140 healthcare facilities around the world, including Rush University Medical Center, Ohio State Wexner Medical, Memorial Healthcare, Vassar Brothers Medical, Wake Forest Baptist Health, Miami Children's Hospital, Vanderbilt University Medical, and University of New Mexico Hospitals.
For those hospitals wishing to get started immediately on improving their patient safety program, LifeWings can come directly to hospitals for onsite training bringing with them the most experienced TeamSTEPPS trainers in the world. Interested hospitals can contact LifeWings for a quick diagnostic call to discuss organizational goals for TeamSTEPPS training. After the call, LifeWings experts can custom design an affordable and cost effective approach that will exactly meet the organization’s needs.
About LifeWings:
LifeWings Partners creates documented, sustainable improvements in cost reduction, efficiency, reliability, safety, and quality by combining the best of Lean and TeamSTEPPS. LifeWings has improved the financial bottom line and patient safety record of over 140 hospitals worldwide. The LifeWings coaching cadre of pilots, astronauts, physicians, nurses and Toyota-trained Lean experts train more than 13,000 administrators, physicians and staff per year. Measurable results are guaranteed in all LifeWings’ initiatives. Documented return on investment typically exceeds 300%. To find out more, please visit http://www.saferpatients.com or https://www.facebook.com/LifeWingsSaferPatients or follow us on Twitter @LifeWingsLLC
Sources
http://www.huffingtonpost.com/2014/01/11/baby-breastfed-by-stranger_n_4578108.html
http://www.myfoxhouston.com/story/24378505/2014/01/06/hospital-mixes-up-babies#ixzz2r3CHUXNO