Monday, August 19, 2013


Policies & Procedures

Create BEFORE need


Lack of relevant policies and procedures is likely to cost the University of Toledo Medical Center (UTMC) at least US$25,000.

According to Lawyers and, a 30-year veteran nurse at UTMC was terminated for failure to stop another nurse from removing items from the operating room before the procedure had concluded. The complaining nurse claims she was also fired for violating policies on communications and logging out.

The story is that the plaintiff was working in the operating room (OR) with another nurse.

The other nurse left the OR for lunch, but, according to the article, failed to log out of the hospital computer system. Returning from lunch the nurse allegedly disposed of a kidney that was waiting to be transplanted.

The plaintiff contends

  • that she had not witnessed the removal of the items and was unaware they had been removed after the other nurse had returned from her break, and
  • that the policies and procedures to prevent such incidents were implemented days after the fact

Could policies and procedures - P&Ps - have prevented the Case of the Disappearing Kidney?

By themselves, unlikely. The article suggests the other nurse violated P&Ps (to log out of the hospital computer system) so at least one person disregarded published policies and procedures. It is possible, but based on the article likely NOT the case, that there was a policy and procedure to identify organs to be discarded.

In addition to the dismissed nurse’s suit, UTMC also is being sued by the family of the person who was supposed to receive the donated kidney.

If, then, P&Ps by themselves are not enough, what can be done to assure they are followed.

As with most things ERM, training, training, and more training, coupled with management flag waving to convince all personnel the reasons for, and the importance of, policies and procedures.

Having effected staff review, and comment on, relevant policies and procedures at least annually enhances awareness while giving the personnel a feeling of ownership.


If I wrote it, you may quote it.

Friday, August 16, 2013


Know your neighbors


I’ve written it before.

I’m writing it again.

Know your neighbors.

Usually the admonishment comes with a suggestion to know what your neighbor does (is the product or service popular or not?), who your neighbor employs (popular or unpopular segments of the population), and how you neighbor treats its personnel (walkouts possible to probable?).

Turns out, according to an Associated Press article in the “” site titled

Salvation Army to be named in Philadelphia building collapse lawsuits

(see, that's not enough.

According to the brief article,

PHILADELPHIA (AP) — The Salvation Army will become the latest defendant in litigation over a deadly Philadelphia building collapse.

Six people died inside a Salvation Army thrift store when an adjacent building being demolished collapsed on them in June.

The suit contends that the Army ignored “known safety risks,” failed to implement protective measures and, due to the this, the Army thrift store customers died.

The army is the latest in the list of defendants.

Did the thrift store management know – have reason to believe – the adjacent building was to come down? Did the neighbors warn the store management? Was pre-demolition work obvious, giving the store management a “clue” of what was to transpire?

At the same time risk management practitioners are well advised to know what’s new with their neighbors, they also are equally well advised to be aware of any municipality activities that might interrupt business as usual.

Celebrations (that could close access roads)

Planned demolitions and construction.

Road work.

Sewer maintenance.

Water line maintenance.

The difference between “business continuity” and “enterprise risk management” in an awareness of what is going on outside the facility and being prepared to avoid or mitigate any threats from outside the facility.

The suit that included the Army thrift store alleges there was something the thrift store management could have done to avoid or mitigate the damage but, the suit contends, management failed to take appropriate measures to avoid or mitigate the threat.


If I wrote it, you may quote it.