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    What Changes Must Occur

First the organizational culture must change from one of blame to one of support for the reporting of errors. Confidentiality of error reporting must be present for this to occur. Next, action plans for system change to reduce and prevent future errors must be implemented. Leadership must become involved to direct and provide support. However, delegation of authority must take place to allow the people involved to take definitive action at the time, not requiring upper management approval first. When empowerment is delegated to the individual or unit level, the decisions can be more reactive and specific to the actual occurrence, and provided in a more timely framework. On the other hand, structure, orientation, training, education, policies and protocols, all initiated or approved by upper management, must be in place to allow appropriate decision-making at the level of occurrence--the actual patient care arena.

Standard and routine processes need to be defined within approved practice guidelines and clinical pathways, which are easily accessible for efficient system flow. Upper management consideration and input are necessary for development of these processes. All relevant stakeholders must feel ownership for organizational system change to become effective.

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