Donald Berwick's Tense Speech Analysis

With his main focus of improving healthcare and trying to provide the best care as possible for patients across the nation through series of campaign in the past that started with 100,000 lives campaign, performing the right surgery on patients and giving patients access to their medical records as need be. On December 2008, Donald Berwick held his annual conference that was entitled the “Tense”, where tackled many improvement ideas and strategies that should be considered in order to achieve the goal of improving healthcare across the nation. In Berwick’s keynote speech, he proposed questions to the public like “what are we trying to accomplished?” “How will we know that a change is an improvement?” and “what changes can we make that will result in an improvement”? He goes on to say that healthcare agencies like the National Health Service shouldn’t just make a change but rather make a change that will result in an improvement of the nation’s
In terms “never events” are basically medical errors that should never occur to a patient. Some of these never events include performing wrong body part surgery, stage III and IV pressure ulcers, performing surgery on the wrong patient, leaving foreign objects inside a patient after surgery or discharging a child to the wrong families. These preventable events that happens in the hospitals, doctors office and clinics have caused death and other form of illnesses or injuries to patients. According to the Joint Commission, never events can be prevented through a series of a root cause analysis. Root causes analysis can identified the cause of the problem and solve it from happening again. These preventable events are caused by situations such as updating wrong information to patients chart or not reviewing patient medical history before performing surgery or