Friday, April 16, 2021

What might go wrong?

In previous blogs, I have discussed preoccupation with failure, which is one of the fundamental concepts of high reliability, or error rates close to zero. Preoccupation with failure is a concept in high-risk industries where the team constantly thinks about how things might go wrong in order to prevent bad outcomes. This is the opposite of assuming that things will go right. When we are preoccupied with failure, we are constantly scanning the work environment and looking for small signs that something is wrong.  

A non-clinical example might be stopping to put a covering over a spill on the floor out of concern that someone might slip on it and fall, rather than assuming that people will see it and walk around the spill or that someone else will clean it up.  

This week, I learned a lot about a great clinical example of preoccupation with failure. Our Pharmacy team is using our Lean Management System to redesign the system for replenishing a code cart after its use. The purpose for this is twofold: we want all code carts to contain the required supplies, so clinicians can use them properly in an emergency situation, and we want to avoid resupplying a large batch of code carts at the end of each month due to expired medications. The team has reviewed the list of required supplies for the carts and created standard work for assuring that everything that should be in the carts is there. They have also created an accountability for training system and a mechanism to check that the standard work is being followed when the carts are refilled. 

To get to very high reliability, we must be mindful and be preoccupied with failure to change the way we see our work. Rather than assuming all is well, we need to watch for signals that a bad outcome may be developing and see “near misses” as opportunities to improve our systems before a catastrophe happens.

Three of Our Own are in Maryland’s Top 100 Women
I am proud to announce that three esteemed members of the GBMC
family were honored by The Daily Record as Top 100 Women.

This year’s selection was special for us because Christina Fitts, a member of our Board of Directors, Ashley McAree, MSN, RN, FNE-A/P, SANE-A, Forensic Nurse Examiner, and Carolyn Candiello, our Vice President for Quality and Patient Safety, were all honored for being “actively involved in their communities while also mentoring the next generation of leaders.” 

Congratulations Christina, Ashley, and Carolyn, we are very proud of you! 

Let’s Go for A Walk
Did you know that our Sexual Assault Forensic Examination (SAFE) and Domestic Violence (DV) program treated 641 victims – 94 of them children – in the year 2020? The COVID-19 pandemic has had an overwhelming effect on the severity and frequency of intimate partner violence, sexual assault, and child abuse within our community.  April is recognized as National Sexual Assault Awareness Month to raise public awareness about sexual violence, educate communities on how to prevent it, and highlight response programs available to the public.  

This year, we are having our 6th Annual Walk a Mile in Their Shoes event, hosted by the GBMC Foundation, which financially supports our SAFE and DV Program. Due to the ongoing COVID-19 pandemic, and to avoid bringing large groups together, we decided again to create a VIRTUAL version of this event.  

Walk a Mile has continued to grow over the years and I am hopeful that, despite these unprecedented times, this year will be no different. Our goal for this year is to reach 2,891 total miles walked, to represent the 2,891 patients who received help from the SAFE and DV Program over the last five years.

We are proud of the impact our program is having, and we are grateful for all the community support that allows GBMC to provide these necessary services across the region. So, I ask everyone to walk or run a mile (or more) and to encourage their friends to do the same, anytime between now and Saturday, April 17, for victims of sexual assault and domestic violence. 

If you’re interested in participating in our virtual walk or want to donate to our SAFE and DV Program, it’s not too late. Please visit for further details. Thank you! 

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