Children’s Hospital and Clinics Harvard Case Solution & Analysis

Children’s Hospital and Clinics Case Study Solution 

Question No.1 What is your assessment of the Patient Safety Initiative at Children’s? In particular, what do you think about blameless reporting?

Patient safety initiative can be attributed as a worth that a hospital could have in its operations, however, the hospital had made efforts conduct focus group studies, and discussions with the hospital staff regarding the gaps in processes or errors in implementing the system. Furthermore, hospital’s patient safety steering committee and focused event studies, these groups helped to identify the systematic failures or individual responsible for the incidents.

Similarly, the hospital had set safety action team, a cross-functional team that was responsible for discussing the medication safety issues and help to improve the system. However, to help the team to discuss the medication issues, there were a Good catch logs in which nurses captured information that could be used to prevent medication errors. On another hand, information was being used for the developing the implementing processes that could help to avoid incidents in the hospital.

The blameless reporting is right at some logical aspects, because if the hospital declares someone as responsible for the incident that takes place, then it cannot eliminate the systemic errors in hospital operations. However, a human mistake or error could also be the result of failure system that does not recognize the processes that could have caused to the incident. Thus blaming an individual would not be the proper approach to safety initiative, if it is, then, how would children’s address it?

Question No.2 What barriers did Morath face as she tried to encourage people to discuss medical errors more openly? How did she overcome those barriers?

Morath faced barriers in dealing with the incidents. Like, it was adil emma for the Morath to disclose the incident information with parents, who asks for the individuals responsible for the incident. So there remains the risk of possible lawsuits against the hospital by the parents. However, due to the blameless reporting system, it could undermine hospital’s ability to hold individuals as accountable for the event due to poor performance. On another hand, Morath could not give her full time to safety initiative, and the team was also found difficulty in measuring the effectiveness of the safety initiatives.

Children’s Hospital and Clinics Harvard Case Solution & Analysis


So the Morath found it “good to do” to disclose information regarding the incident, not by legal aspect, but because, she thought that it is a good thing to do, then later Morath changed her opinion to disclosure policy along with the support for the staff. Similarly, the children’s adopted policy of just culture, in which no individual is held responsible for the system failure, but there remain some identified key problems to address the possible human errors, reckless behavior, and at-risk behavior, and failure paths as well.............................

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