Monday, July 18, 2005


the buck stops here

The patient had just arrived in the critical care unit (ccu) from the emergency room. He had been well stabilized and was doing well. All was going smoothly. He was attached to the ccu's cardiac monitoring system and taken off the portable monitor used for transport to the unit.

His heart rhythm was fine. The nurse began to enter his information into the monitoring system: his name, age, and gender. Unfortunately, his last name starts with "G".

It seems the keyboard's "G" and "N" keys just do not work.

There is no way to enter him with the correct name, but the monitor strips are a real and vital part of the medical record, and wrong names on medical documents, especially key data such as live cardiac rhythm monitors, can lead to serious or deadly errors.

But a keyboard costs only about ten dollars today. I am sure the hospital has plenty of replacement keyboards, for they are the most likely part of the heavily used system to break.

The nurses were busy, so I called "IT" -- information technology department. Unfortunately, they do not handle repairs to equipment keyboards or monitors, only to computer systems. "Call maintenance".

The maintenance guy did not know ANYTHING about monitors or keyboards. He suggested, "Call IT. "

So.... I took a working keyboard off of a computer terminal and put it on the cardiac monitor system. Mr. G. could now be "in the system".

The faulty keyboard was now on the computer terminal. NOW it is IT's responsibility.

At least that was one, albeit roundabout solution to the immediate problem.

The next day I called and spoke with the hospital's VP in charge of maintenance. I told her the story. As I have suggested for, oh, 20 years, I once again suggested the establishment of a "buck stops here hot line". 24/7: a phone number that ANYONE in the medical center with ANY unusual problem can call and have a well trained and well authorized problem solver take on and handle any problem. I suspect the efficiency ad cost savings would be immediate and immense. Rather than having a clerk or nurse or doctor spend long and inefficient time and effort to solve a problem, a delegated problem solver could handle it in seconds!

She will get back to me. We'll see.

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