QUESTION
How does New York City Health and Hospitals (HNH) address medical malpractice and prevent it from happening again?
2:11:26
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150 sec
New York City Health And Hospitals (HNH) investigates every case of medical malpractice or potential error, instituting corrective plans to prevent future occurrences.
- Every incident, including 'good catches' where no harm occurred, is reviewed at both the facility level and system-wide.
- Corrective plans are developed for each incident to ensure similar errors don't happen in the future. This might include training programs or procedural adjustments.
- Emphasis is placed on using two identifiers, such as name and date of birth, for patient identification to reduce the risk of misidentification.
- Changes to medical procedures or the adoption of different medical devices are considered as part of preventive strategies.
Mercedes Narcisse
2:11:26
When medical malpractice occurs, what step does h and h takes to ensure that it should never happen again?
Mitch Katz
2:11:33
Well, every case where something goes wrong, including what we call good catches, where something could have gone wrong.
2:11:41
So even if nothing has gone wrong, say someone is misidentified.
2:11:48
Mhmm.
2:11:48
I reviewed a case recently where someone goes into a waiting room, calls a name, and the wrong person answers.
2:11:59
Right?
2:11:59
And there was no, you know, check of date of birth until much later.
2:12:03
Nothing bad happens.
Mercedes Narcisse
2:12:05
Mhmm.
2:12:05
Thank But
Mitch Katz
2:12:06
we still look at that case.
Mercedes Narcisse
2:12:07
Yep.
Mitch Katz
2:12:07
That is kit that is a good catch.
Mercedes Narcisse
2:12:10
Mhmm.
Mitch Katz
2:12:10
Someone caught the case and realized, oh, no.
2:12:12
You're not this person, nothing happened, no negativity.
2:12:17
Mhmm.
2:12:17
So every case where either so something goes wrong or there is a good catch where something could have gone wrong.
2:12:26
Someone ordered a medication that was contraindicated.
2:12:29
So and ordered an amount that was contraindicated.
2:12:32
Each of those is reviewed at the facility.
2:12:35
And then as a system with our board.
2:12:38
We review a set number of cases at every single hospital.
2:12:43
In every case, we are something went wrong or could have gone wrong has to have a correction plan of how do you make sure that it never happens.
2:12:54
Often, it's a can be a teaching program.
2:12:57
So for example, reminding people, names are a terrible identifier.
2:13:03
People have the same name, people change names, 2 identifiers.
2:13:08
Everybody has to have 2 identifiers.
2:13:10
If you're in a healthcare system and you're not asked your name, date of birth each time, there's a problem.
2:13:17
There should always be 2 identifiers.
2:13:19
So it's constantly reminding people, did you ask what their date of birth is, not sufficient to just ask their their name.
2:13:27
Sometimes it's putting a process in place.
2:13:31
We're not going to use this catheter.
2:13:34
We're going to use this catheter.
2:13:37
So each case is very individual.
2:13:40
Each one is reviewed with and required to have a plan of how to prevent this in the future.
Mercedes Narcisse
2:13:46
Mhmm.
2:13:47
Thank you.
2:13:48
We usually do date of birth, name, and check the bin, the ID.
Mitch Katz
2:13:51
Yes.
Mercedes Narcisse
2:13:52
Because that way, you know, is that person.
2:13:54
I think my colleague have another question.
