Article on Quality Problems in Healthcare

[Indy Lurker]

Interesting article comparing an ISO 9001 type system used in manufacturing as a tool for health care.

http://www.qualitydigest.com/currentmag/articles/03_article.shtml


"ISO 9001 prevents malpractice
The Torajee Bobbett malpractice case that was recently settled for $11 million in a Pennsylvania court involved the following problems:

• Two nurses who treated the patient weren't certified in a pediatric life-support course, even though their job description required it, and the emergency room physician wasn't certified in emergency room medicine. Nurses in the pediatric unit didn't know how to read a cardiac monitor. ISO 9001 requires that an organization identify the requirements of each job and verify that each person assigned to a task is qualified to perform it.

• The hospital failed to record the patient's weight, which might have shown that he wasn't getting adequate fluids. ISO 9001 requires an organization to have a mechanism for ensuring that products (or patients) receive all necessary tests and measurements, that the results are recorded and that corrective action is taken if they're out of specification. "





"...An even more infamous case occurred when a woman was killed and two sets of transplant organs were wasted because she was given a heart-lung set of the wrong blood type. This also probably cost the life of another patient who could have been saved by the first organ set.

Such catastrophes are almost impossible under ISO 9001-compliant systems because the standard has very strict requirements for product (or in this case, patient) traceability. Parts in factories rarely get the wrong process recipes, and the same applies to mix-ups in test results and other quality records. If factories apply state-of-the-art product traceability and data-integrity assurance techniques to inanimate products to avoid wasting money, there's no excuse for wasting human lives by not using the same methods in health care."