Working Together For Safety

Dr. Chessare is on vacation this week.  Guest blogging is Carolyn Candiello, GBMC's Vice President, Quality and Patient Safety.

As I approach my one-year anniversary this fall of joining GBMC HealthCare as Vice President, Quality and Patient Safety, I find myself continually impressed with the strength and commitment of my colleagues. 

For example, soon after I started, the mother of one of our patients sent me a letter sharing some thoughts about how care might be improved in the Neonatal Intensive Care Unit (NICU). She and I met to discuss her ideas, and GBMC’s Chairman of Pediatrics, Dr. Timothy Doran, took time out of his busy administrative and clinical schedule to attend and hear the parent’s thoughts first-hand. At a lot of hospitals you wouldn’t find a clinical leader who takes the time out of their day to do that. We listened to the mom’s feedback from her experience and she offered some good suggestions about ways we could improve our care. Dr. Doran and I subsequently met with the rest of the clinical team and they implemented changes to improve and enhance the patient care experience in the NICU.

I also reflect back on the leadership off-site in March.  My colleagues and I spent time learning about how errors occur and how to design our processes and strengthen our behaviors to prevent them.  When looking at an error it is easy to focus on “the sharp end” or the person closest to the error.  This might be the nurse administering the medication or the tech assisting a patient out of bed who falls.  However, knowing that “every system is perfectly designed to get the results it gets” we recognize that failures in our system occur anywhere along the continuum of the process.  Strengthening our processes can make care safer for patients and provide more joy for those at the bedside. 

The best example for understanding errors is Reason’s Swiss Cheese Model.  Looking at this model, we can see that errors occur when failures in our process line up.  We also can see that errors can be prevented when we block the holes through safe system design and using safe behaviors. 

Safe system design can be anything from a simple checklist to redesigning our information system for safe medication ordering.  Safe behaviors such as “having a questioning attitude” can also help prevent errors.  Not long ago, I learned about a situation where a nurse saw that a physician had ordered a medication for a patient that didn’t make sense for that individual’s treatment.  Using a “questioning attitude” the nurse appropriately questioned the physician and it turned out that she had intended to order that medication for another patient.  In turn, the physician’s response and gratitude for the nurse’s “good catch” demonstrates another safe behavior of “working together with your team”.  While this error never reached the patient, we are grateful that she reported this to us as it helped to understand some holes in process which have been fixed.

Learning about incidents such as these is a gift to those of us who work in quality and patient safety here at GBMC. It may seem counter-intuitive that we’d want to hear reports about times when something goes wrong or “almost” happens, but every incident report we get is a treasure because it gives us a chance to see where there may be holes in our process and allows us the opportunity to make care safer.

Recently we became aware of some instances where our process for patient identification wasn’t followed as designed. While we have a great system for medication administration using bar code technology, there are other times when this technology is not available to assist us—for example identifying patients for treatment, transport, nutrition and outpatient medication.  At GBMC we ask the patient to state their name and date of birth.  We then compare that to the patient's name and date of birth on the order or requisition.  Finally, we look at the patient's identification bracelet to confirm the correct name and date of birth.  But add in other complexities and interruptions and it’s easy to get ourselves into “auto pilot” and miss one of these important steps—we’re human after all.  A good tool to help is “S-T-A-R”!

• Stop, pause for 1-2 seconds and focus on what you are about to do
• Think, think about what you are doing– is it the right thing?
• Act, concentrate and take action to perform the task
• Review, do a self check to review if the task was done correctly

“S-T-A-R” is not just designed for clinicians, it’s a good tool for all of us to use in situations where the potential consequences might involve high risk or will require a lot of re-work if not done correctly.  For example, it is a great tool to use before sending an important email; or at home, it might be helpful to use the tool before locking the door (with the keys on the other side!) or paying a bill electronically (did I get the decimal in the right place?).

I am looking forward to sharing and learning from each of you over the coming months as we work together to improve our system of care.   I am both pleased and proud to be a part of GBMC and thank you all for what you do every day to keep our patients safe. 

If you have any stories you would like to share about safe behaviors or redesigning systems please comment below.  Also for GBMC employees, please follow the Patient Safety group on Yammer (GBMC’s Social Network).  Go to www.Yammer.com--sign up using GBMC email and join the conversation!