September 7, 2016
Read the original news story on the Post Gazette

Here is a tragedy that happened in my county -- and need not have happened at all. Two areas where I'd love to help these families and hospitals avoid such tragedies: 1) Always assume a physical problem is exacerbating a psychiatric presentation; and 2) Develop a cause map to objectively determine systemic solutions to the problems JUMPING OUT AT ME FROM ALL OVER THIS ARTICLE. It's a scene that happens ALL. THE. TIME. This is so very doable but it's the same scenario I've witnessed for two decades. That is, well-intended professionals in these environments don't seem to know how to make it better and don't believe that it can get better. They also are busy chasing after the emergent issues such that they can't get to deep and lasting problem solving. Too much QI is focused on delegating to untrained people and collecting/reporting data.Then, it all gets far too routine as long as fund-er checklist requirements are met. If there is any surprise here, it's that this isn't happening more often. This is where a skilled outside consultant can save lives, dollars, and make lasting positive change.

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