On Thursday, March 6, 2008, Dr. James Miser, former CEO and Chief Medical Officer of City of Hope National Medical Center, was invited to speak to Min-Sheng Healthcare administration, physicians and staff on the subject of "Improving Healthcare Quality through Root Cause Analysis." Besides being the CEO and Chief Medical Officer beginning in 2001, Dr Miser is a world renowned pediatric oncologist and father of 10 adopted children.
Dr. Miser stated he has always had an interest in patient safety. The physician oath says first do no harm. "Medicine use to be simple, ineffective and relatively safe. Now it is complex, effective and potentially dangerous," he stated.
According to a 1998 released by the Institute of Medicine, "44,000 to 98,000 people die in the United States health care system each year due to preventable errors made by health care practitioners."
A systems analysis approach can be used to thoroughly evaluate all patient care systems, identify areas of risk, implement changes to mitigate risk and prevent errors before they happen. Dr. Miser shared several examples of how a systems approach identified errors before they occurred and several stories of errors discovered through a systems analysis approach after the errors had been committed.
Dr. Miser also told several stories of errors and potential medical treatment errors that involved his own children, noting that if these situations could happen to his family then it could certainly happen to anyone. Dr. Miser believes that a “no blame” culture is essential if you want to change a hospital system. In a “no blame” culture you accept that an error can occur, but it also provides an opportunity to make the hospital a safer place.
A "safe hospital" in Dr. Miser's words is one where there are excellent physicians, an excellent staff, excellent systems, and excellent patient involvement in care and education. In describing each aspect of a "safe hospital, Dr. Miser pointed out the importance of hospital leadership create a culture of safety by reporting errors without a fear of blame or retaliation is key to accurately implementing system changes. Most medication errors are due to system errors not incompetence. While reporting errors can be a frightening thing for a hospital system, it is necessary to report errors accurately to be able to change the system and make it safer.
Dr. Miser graciously answered questions from the audience and discussed his medical philosophy with other audience members after the presentation was completed. He completed his day with a tour of Min-Sheng General Hospital followed by lunch with Dr. Fred Yang, the CEO and Mrs. Connie Ma, the Chief Quality Officer of Min-Sheng General Hospital.
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