Friday, January 14, 2011

Redesigning our Systems, Renewing the Culture of Safety

The tragic shooting that took place in Arizona this past week has many people questioning their safety. The individuals who were injured or tragically killed by the gunman went to a public forum never thinking twice that it may be an unsafe place. Our hearts go out to the victims of this senseless shooting and to their families.

Our patients come to GBMC trusting that we will provide the safest, highest quality care. We must rededicate ourselves to making our health system as safe as it can possibly be. That our patients are safe while in our care must be a given. It is our duty to them.

I am delighted that Carolyn Candiello has joined us as our Vice President for Quality and Patient Safety. Carolyn and Dr. John Saunders, our Chief Medical Officer, are redesigning our Quality infrastructure, beginning with the creation of a Quality Committee of the Board of Trustees.  

As we reinvigorate our quality oversight system, it is a good time to stop and take our patient safety “pulse.” This is why we’re rolling out the Safety Culture Survey to those individuals with direct patient care responsibilities on January 19. The survey results will help us redesign our patient safety practices, help us improve reliability and strengthen our culture of safety.  When it comes to patient safety, think of it this way:
If it were your daughter, “pretty safe” would not be good enough.
I often use the example of the airline industry to demonstrate just why “pretty safe” doesn’t cut it when you have the lives of others in your hands. In the 1980s and early 90s we would have at least five or six major airline disasters per year in our country. Today, these types of air catastrophes are virtually unheard of. Why? Because the safety systems have been diligently redesigned.

And now, everyone involved in flying a plane follows the design. Pilots, co-pilots and air traffic controllers don’t do whatever feels right in the moment. They follow the rules. They follow a checklist so that disasters like the one that occurred on Northwest flight #255 out of Detroit in 1987 never happen again. This plane crashed into a light pole, a rental car building and eventually a highway overpass only a short distance from the end of the runway. In a rush to depart, the crew took off with the wings configured for landing instead of takeoff, needlessly killing more than 150 people.

And in 1977, in what is described as the worst commercial airline catastrophe in history, the KLM/Pan Am crash claimed the lives of more than 550 passengers on the Island of Tenerife. Because of an entire series of unfortunate events including misinterpretations of instructions, miscommunication, not running through a checklist, human error and not speaking up when something was not right, another tragic human disaster became a piece of history.

A prime example of how some clinicians at hospitals are still not following the rules that were designed to keep patients safe is in the use of unsafe abbreviations. It’s inevitable that if a clinician uses the unsafe abbreviation enough times, someone is going to get hurt. If pilots take off without running through the checklist, eventually a plane is going to crash.
We must do the right thing for our patients, every time. We must all learn to speak on behalf of our patients and not hesitate to stop any practice deemed unsafe regardless of who we need to challenge. I’ll never forget an interaction I had well into my career as a pediatrician. It was a Friday at 5:15 p.m. and I was in the car on my way home when I received a call from a pharmacist. I had written a prescription for a patient for a malaria prevention drug that I didn’t use very often. The pharmacist called me very sheepishly to question me about the prescription, wanting to double check the dosage I wrote down. I took the time to go through the calculation with her and we both concluded the dose was correct. She apologized up and down for bothering me, but I thanked her for having the courage to call. She did the right thing. She was protecting the patient.
Regardless of a person’s rank, title, training or position, it’s always OK to speak up when something seems wrong or out of place – it’s everyone’s responsibility to protect our patients!
Let’s get thinking about this, folks.
The notion of vigilance will only take us so far. We must emphasize reliability.
Being well-trained, hard working and caring is just not enough to keep our patients safe 100 percent of the time. It’s time to take action and redesign our systems! We’re taking the steps to do this and I urge everyone to play their part in this culture of safety.

So, if you receive the Safety Culture Survey in the coming weeks, please fill it out. We need to find out where we are today so that we can redesign unreliable and unsafe practices to make our care even safer than it is today.  

What if it was your daughter? You’d expect nothing but the best.

Do you have an example of someone doing the right thing to protect the safety of a patient? I’d love to hear about it – Please post a comment so that all of our colleagues may benefit or send me an email at

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