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Briefing and Opinion
October 22, 2004

Risk Management's Role

Stress Factor
Risk management can do much to promote a climate of truth telling and bolster the current willingness to confront the realities within health care systems. Only from this basis can real improvement proceed. The human factor in health care -- the emotional commitment of health care professionals and their willingness to bring the very essence of their person to the care of patients -- cannot be ignored. To injure a patient through error can be devastating to a health care professional or caregiver. Those professions and caregivers who become victims themselves of imperfect systems and inadvertently inflict harm must be supported.

Source: MEDICAL ERROR, edited by Marilynn Rosenthal and Kathleen M. Sutcliffe of the University of Michigan, Chapter 7, Risk Management and Medical Errors by Margaret Copp Dawson, Ann P. Munro, Kenneth J. Appleby, and Susan Anderson.



Mindful Interdependce

What can medical people do right now to begin to reduce medical errors?

The best answer I have heard comes from Winston Churchill. During World War II Churchill made a colossal error when he failed to realize how vulnerable Singapore was to attack by a Japanese land invasion. This error led to Singapore's downfall. In Churchill's equivalent of an M and M review after Singapore's collapse, he asked four questions, every one of them a systems question. He asked: why didn't I know? Why wasn't I told? Why didn't I ask? Why didn't I tell what I knew? (Allinson, 1993, pp.11-12). Those four questions are questions of interdependence. They take seriously the idea that knowledge is not something people possess in their heads but rather something people do together.

Source: MEDICAL ERROR, edited by Marilynn Rosenthal and Kathleen M. Sutcliffe of the University of Michigan, Chapter 9, Reduction of Medical Errors Through Mindful Interdependence by Karl E. Weick.