JCAHO’s Positive Response to Critical Issues: Patient and Specimen Identification Errors

The July 2002 issue of OUTCRY Magazine is dedicated to medical errors. Many of its articles are about the search for solutions to medical errors, based on our ongoing study of error prevention in health care institutions. What people on the outside of health care do not realize is, there are many systemic problems associated with the continuation of medical errors. Problems within the system and problems outside the system are impeding the quality of care. Based on research study to date, evidence indicates that even though known best practices are presented to health care professionals, health care organizations have not been eager to incorporate these known practices into their daily procedures to help improve the quality of patient care. This is similar to the observation made in our ongoing national campaign and research on medical errors. Our study, like others, encountered many types of resistance to solutions implementation and other ideas to improve the quality of care. From our study, it is evident that solutions can neither be engineered from the bottom (front-line workers) nor starting from the middle (technical managers). Such attempts will not be as successful. The best solution is for the initiation of coherent effort to be championed and fired-up by the hospital CEO and the hospital medical director.