CMS response to cancer misdiagnoses due to lab errors
blatino at RELIABILITY.COM
Tue Mar 20 16:16:32 UTC 2018
The hospital corrective action plan is weak (based on the one paragraph explanation they provided).
Where was the management oversight to detect all of those 'now visible' deficiencies in qualifications, equipment deficiencies and less-than-adequate (LTA) quality processes?
Why didn't the staff who worked daily in the presence of these obvious deficiencies, feel comfortable to speak up? OR, did they speak up and weren't heard (or listened to)?
Their response is the typical 'retrain and revise procedures' approach while overlooking the systemic deficiencies, restraining cultural paradigms and sociotechnical factors, that permitted the 'drift' to occur in the degradation of standards. This is often the case when seeking to be compliant versus safe.
How come most of the ~6000 hospitals in the U.S. are accredited yet the medical error death rate continues to climb (since magnifying glass was focused on the topic of patient safety in the 1999 IOM report)?
Robert J. Latino, CEO
Reliability Center, Inc.
blatino at reliability.com
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