People die because changing the system is so hard
My post yesterday was about making systemic change. My point was that we do a lot of stuff locally that really should be implemented at a State or Federal level.
But let’s look at the other end: signal detection.
In recent times I’ve noticed that it is almost impossible to get a decent fluid balance record on the wards. The consequence: failure to recognise that a person emptying a full stoma bag every hour has severe diarrhoea and that 12 hourly bags ain’t going to replace the fluid losses. What’s more there were no measures to stop the diarrhoea.
We can report this incident but to be honest it isn’t enough to address the educational problems nor address the cultural issues at stake.
I’m told there is a Clinical Business Rule (CBR) around this problem but heck….who is thinking of these and how the fuck do you find them when needed. I bet none of the residents know they exist let alone know how to find them.
CBRs are good governance but poor practice….we need ways to trigger appropriate responses not just to the deteriorating patient but those at risk of deteriorating.