- Hospitals can’t find the problem. Hospitals cannot identify in their own records all their errors, accidents and infections, even though they are required to report many of them to the federal government.
- Hospitals can’t figure out how to solve the problem. Despite a large body of research about how to address most safety problems, hospital leaders can’t seem to find the time to read it. Some hospitals even admit to throwing a bunch of ideas at a problem at once – surprised when it becomes nearly impossible to tease out which ones worked, and which didn’t.
- Nobody does what they are told anyway. Even when hospitals identify a problem that is hurting patients, and commit to an evidence-based solution to stop the harm, they can’t get their staff on board.
“Ultimately we need to tie system payments to the effectiveness of interventions.”
