Middle Tennessee Hospitals Admit Mistakes and Fix the Causes

According to a recent report by the Tennessean, Middle Tennessee hospitals are more willing to admit their mistakes and change the way they do business to better serve their patients.

Middle Tennessee hospitals have reported over 12 serious medical errors in Tennessee over the past three years. According to national statistics, another 80 errors were never reported.

These numbers have prompted the region’s hospitals to rethink how they deal with these errors. Rather than trying to cover the mistakes to avoid lawsuits, or simply punishing personnel and going back to business as usual, these Tennessee hospitals are looking into causes and solutions.

Nashville’s Baptist Hospital has begun this new way of dealing with mistakes. In 2009, a baby in the neonatal intensive care unit died when a nurse mistook the feeding and IV lines. The hospital took a proactive stance and studied the causes for the mistake.

As a result, the tubing is now color-coded and nurses have changed the way they check the lines. Other changes have taken place at Baptist Hospital as well:

• Neo-natal nurses must now have an observer when working with the tubes.
• They must also never be interrupted and must keep visual contact at all times with the babies.
• When preparing medication doses, nurses at Baptist now can flip a sign reading “No interruptions please”.

According to Deborah Roberts, Baptist Hospital’s director of quality/risk management, “There are humans and there are systems. We had to look at the system error about was was going on. We had to correct the system there.”

Roberts says that only one “serious safety event” was reported last year, compared to 17 in 2008. With numbers like these and continued efforts to reduce patient risk, it is hoped that these changes in hospitals will create a new culture of caring.