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 ...view middle of the document...
Few focus groups were also created with the involvement of parents. This gave an opportunity for the parents to speak openly about there own experiences and give suggestions to improve the system.
To implement, Morath wanted to first transform the organizational culture to provide an environment conductive to discussing medical accidents in a conservative manner.
Proposed Ans for the Q at Page 14 of the case
Questions that Morath has to answer to the parents or the Family of Mattew’s
1. What are the names of the individual responsible for Matthew’s overdose?
This Q is a classic case of Right vs. Right dilemma. The 1st right being the hospital’s policy of disclosing every thing to the relatives and family of the patient. The 2nd Right being their practice of “Blameless reporting” in which no individual is blamed for an error or an “accident”. Instead system “failure” and process failure are discussed.
So this Q can be answered by saying that no particular individual was responsible for the overdose and instead a system failure occurred. This has been taken into account and has/is being “examined” thoroughly by the “Patient Safety Steering Committee” (PSSC). A modified system will be in place ASAP so as in the future no such issues arise.
2. How could they make such a serious mistake?
This Q can be answered by saying that it was not a mistake, but an accident, which...