Chasing Zero

Last night in my Health Care Systems class we watched part of a nearly-hour-long video that I’d like to share with you. I watched most of the rest of it when I got home last night; got sleepy with about 10 minutes to go so haven’t seen the very end yet. But it fits beautifully with Mayo's whole Culture of Safety initiative and puts human faces on the critical nature of the culture of safety. It’s called Chasing Zero. It’s really worth your while.

Camping, and diagnosis momentum

I hope you had a lovely weekend.

We camped with our daughters in the Yellow River State Forest to our south. We hit the Harper’s Ferry Volunteer Fire Department’s pancake breakfast on Sunday. The campground was overrun with hungry tent caterpillars. My girls invented a new game called Hunger Games for Tent Caterpillars, which involved tossing the “tributes” into the campfire. The survival rate was nil.

Here’s an article that talks about how errors in one part of the medical record can be copied and passed on if they are not verified, until they are all over the patient’s chart and then nobody believes it’s a mistake. The article calls this “diagnosis momentum, a phenomenon whereby ‘once diagnostic labels are attached to patients they tend to become stickier and stickier.’” This was not a transcriptionist’s mistake in this case, but I have seen it happen that way too: The first error is a transcription error, the dictator signs off on it without noticing the error, and it runs from there, gaining momentum with each new provider who reads it and then dictates into the record once more. (I think you will probably have to register for the site to read the article but it's free, and they have great stuff.)