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Goal Goal in Point of Care? Goal in the Laboratory? Goal in the Hospital? To Err is Human - Building a Safer Health System A Report From The National Academies of Science, Institute of Medicine 44,000 – 98,000 patients killed each year by medical mistakes Key Recommendations Center for patient safety National mandatory reporting Peer review protections Focus greater attention on patient safety FDA should increase attention to safe use of drugs It is necessary to create a culture of change that embraces patient safety through shared accountability within a blameless culture. Rosina Jones, LHRM, CHRM Causes of Medical Mistakes 60-80% is human error Active errors Three approaches to quality Remedial Alleviate the symptoms of the existing problem Corrective Eliminate the cause of existing problems or undesirable situation to prevent recurrence Preventative Eliminate the cause of potential problems Changing the process “er” – Season finale Romano’s accident Is 99.9% Good Enough? 1 hour of unsafe drinking water every month; There will be no telephone, electricity or television for 15 minutes each day. 315 entries in Websters Dictionary will be misspelled 114,500 mismatched pairs of shoes will be shipped/year 811,000 faulty rolls of 35MM film will be purchased this year. 880,000 credit cards in circulation will turn out to have incorrect cardholder information on their magnetic strips 2,488,200 books will be shipped in the next 12 months with the wrong cover. 5,517,200 cases of soft drinks produced in the next year will be flatter than a bad tire. 1,314 phone calls will be misplaced by telecommunications services every minute. 18,322 pieces of mail will be mishandled/hour 22,000 checks will be deducted from the wrong bank accounts in the next 60 minutes. 2,000,000 documents will be lost by the IRS this year Your heart fails to beat 32,000 times each year. Twelve babies will be given to the wrong parents each day. 2,500 newborn babies will be dropped in the

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