10.8 End-of-Topic Case: Healing Preventable Mistakes

Have you heard of iatrogenic harm? It is harm caused inadvertently by the process of healthcare treatment. Unfortunately, medical errors harm a significant number of Americans. Shockingly, death by medical mistake or accident is the nation’s leading cause of accidental death.

A case in summer 2021 illustrates the nature of the issue. Surgeons in a Midwest health facility transplanted a donor kidney into the wrong patient, while the patient designated to receive the kidney had to return to the waiting list. Similar cases involve the medical operation of the wrong organ or surgical procedure on the wrong side of the body.

Let's imagine that a Midwest hospital hired Dr. Camille as the new CEO to oversee a 6,000-bed health system that includes the main campus, 19 hospitals, and over 200 facilities. Dr. Camille displayed the business acumen, healthcare expertise, and forward thinking needed to lead complex operations and maintain the overall health and effectiveness of the facilities.

Building on her knowledge of lean six sigma, she decided to look at the iatrogenic harm statistics for the hospital. Let's suppose she found figures similar to the national average and decided to tackle the issue. She found a common problem involving patients undergoing surgery on the wrong side of the body, such as the right arm or leg instead of the left. She assigned you to look into the problem and propose solutions.

Questions

1. Which change concept(s) may be most applicable to this situation?

2. Use the change concept you identified in the previous question to propose potential simple solutions to the problem.

3. Pair up with a classmate, compare your answers, and produce a consolidated report.