Reading Response 6: Reporting System

In the health care sector, even though putting a lot of attention to it, there do exists deadly accidents. It doesn't mean the doctors or nurses are all bad apples, but for the health care area is so complicated that even a slight mistake can lead to catastrophies and it still remains a lot of unkown knowledge, which need continuous practise. Usually, when medical errors occur, they are punished, fined or even sued so that they fear to volunteer information about problem areas that are in need of improvement, which has no benefits to gain experience and improve patient's safety. As a result, someone else will make same mistakes and threaten more lives, which is actually a vicious cycle. The right activity should perform in this way,

It is urgent to recognize that "blaming and shaming" attitude is inappropriate because it does little help to reduce tha rate of incidents. It is crucial to know“inevitable human fallibility and how feedback at the organizational level can play a critical role in identifying errors, fixing problems that cause errors, and thereby enhancing patient safety”.
Due to the legal liability and the medical culture of personal accountability, we should consider developing a reporting system like the one applied in the aviation area, the ASRS(Aviation Safety Reporting System). The five design principles can also be adopted by the health care sector. The principles are:
1.Voluntary. "No one has to report, but anyone can."
2.Confidential. The system protects private information about the one who report errors, such as the identitication, preventing them exposed to public.
3.Non-punitive. It can protect them from getting harm to their reputation, not to be blamed.
4.Objective. It is suggested that the system should be operated by a respected, authoritative third party to index information and create the database.
5.Independent. The reporting organization can not regulate the medical staff.
Obeying those principles, they will not fear reporting errors and provide resourceful, invaluable profiles to improve the health care area.

What I have learned from the chapter"Management Matters" can also make sense to the education field.
Students are normally afraid of having exams and getting scores, because teachers and parents may blame them, and they may be shameful of relatively poor learning outcomes. Do not keep yourselves in the passive mood, just regard exams as the instrument to identify studying problems. "We can not undo the past, but we can learn from it by looking to the future".