Introduction
The Protagonist, Julie Morath, is the CEO of Children’s hospital and Clinics and has a dilemma of how to answer the Matthew’s families’ questions relating to the occurrence of the accident where Matthew was overdosed with morphine. Julie Morath, bringing with her 25 years of experience in patient care administration to the hospital, her main aim was to highlight patient safety and to create a culture where the concept of ‘do no harm’ was explicit rather than implicit.
It was very tough to implement as doctors and nurses were not open to discuss any “accidents”. It is an example of classical conditioning as the doctors and nurses used to get defensive when they were broached on the topic of safety. To them, talking about safety implied that that they were doing something wrong.
To introduce the idea of enhancing the patient safety, she had to take the doctors and the nurses into confidence. This could only have happened when this plan was implemented slowly. To achieve this she spent time making presentations to hospital staff about national research on medical errors. Then she conducted focus groups to learn more about patient safety issues. Finally she developed a detailed strategic plan for the Patient Safety Initiative.
Many problems arised when she tried to present medical accident data to the nurses and the doctors. They were sceptical of the applicability of the national data. To this problem, Morath asked the staff to examine their own experience that week regarding patient safety and was it satisfactory? After discussion they realised that most of their colleagues had experienced similar medical accidental events and were convinced that errors were indeed a problem.
The culture of health care must be one of everything working together to understand safety, identify risks, and report them without the fear of blame.
Focus groups were