Guest Post: Libby Zion

Today’s guest post is by James Lawther.  James gets upset by operations that don’t work and apoplectic about poor customer service.  Visit his web site “The Squawk Point” to find out more about service improvement.

On 4th March 1984 Libby Zion (an 18 year old known to be using anti-depressants) was admitted into a hospital in New York with a high fever.

That night, Luise Weinstein, a medical intern 8 months out of medical school, was on call. He discussed her case over the phone with a senior doctor, and then prescribed two drugs, a pain killer and a sedative.

The next morning Libby was dead.

The subsequent inquest found that a reaction between the two medicines and her anti-depressants was the cause of Libby’s death.

Why was she prescribed those drugs by the medic? Didn’t he know what would happen?

It transpires that like all medical interns he had been working a long shift. He was over worked and sleep deprived and made the wrong decision.

How long do you work?

How long can you expect somebody to work? In the UK and US there are laws that prevent lorry drivers from working more than 11 hours without a 10 hour break.

11 hours is also the time it takes to fly from London to Los Angeles. Would you get on a plane flying the return leg if you knew that the pilot had just flown the outbound trip?

That shift, Luise Weinstein had worked 36 hours.

A change in the law

Libby Zion’s father happened to be a journalist and he did what all good Journalists do. He created a story, a mass of publicity. In response the governor of New York set up a committee to look into the case and in 1989 the law changed in New York State forbidding Medical residents to work:

  • More than 24 consecutive hours
  • More than an 80 hour working week

Remember that plane trip?

Ten years later the New York State Department of Health conducted surprise inspections at a number of hospitals. They found that over half of surgical residents work in excess of 95 hours a week .

Why do the hospitals flout the law? Simply because it would cost them a lot of money to obey it.

The problem with focusing on cost

Lean thinkers talk about purpose, they say you should always focus on purpose first and foremost. If you do that efficiencies and cost savings will come as a by-product.

Hippocrates is often quoted as saying “first do no harm”.

Perhaps that would be a good purpose for the hospitals to focus on.

James writes about process improvement at www.squawkpoint.com

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Posted on August 23, 2012, in Error Proofing, Guest Post, Health Care, Improvement and tagged , , , , . Bookmark the permalink. Leave a comment.

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