Why Patient Safety, Teamwork, and Risk Management Matter to Me
Eight years ago today, I lost one of the most important men in my life-my Dad due to a patient safety error. Words cannot express how much I miss him.
My family’s loss was tragic, but also unnecessary.
An average of 200,000 Americans die in hospitals annually from preventable medical mistakes.
That is the equivalent of 390 jumbo jets full of people, every year.
Three hundred and ninety. Let that number settle into your bones for a second…
A lack of basic Patient Safety measures had a catastrophic consequence: It cost my Dad his life. In an instant, his life turned into a statistic. This same wicked twist of fate could happen to you and your family as well. We are all vulnerable. So Patient Safety and Risk Management should concern us all.
When there is a lapse in Patient Safety, it steals our spouses, parents, children, grandparents and friends.
There’s no question, had a culture of Patient Safety been prevalent in the operating room, I wouldn’t be writing this post.
My Dad was a former United States Marine Corps Aviator and a Delta pilot for 36 years. Safety was always his number one concern.
The safety of his crew and the safety of his passengers were not a responsibility he took lightly. As a child I would ask him when things got bad in the airplane, be it weather or mechanical issues, if he ever worried about getting his passengers home safely. His reply was always simple: “As long as we know our procedures cold, continue to fly the airplane and talk to each other, the two of us upfront will be ok—and that means everyone onboard will be ok too… And they love their families as much as I do.”
Processes Matter to Patient Safety
Today’s military and commercial aviation communities use processes that keep them 99.9996% accident free.
These processes cover skill sets for teamwork, clear communication, discipline, collaboration, standard protocols, self-incident reporting procedures, and decision making.
In the aviation industry, the concept of “Crew Resource Management” empowers anyone on the flight deck to challenge another pilot if they see a potentially fatal blunder in the making.
Although some progress has been made, the skills and straightforward process required to function as a high performing team—establishing purpose, accountability, resolving conflict, effective communication, learning to trust each other—are often still lacking in this sophisticated environment.
Ego: The Enemy to Culture Change
Operating rooms have fragile cultures. Egos can get in the way, and surgeons are often treated with complete deference because of their sophisticated skill sets, and as a result there is hesitancy for nurses and other staff to speak up – even if they see a problem.
Understandably, the atmosphere in an operating room can be tense.
However, poor communication between hospital support staff nurses and surgeons is the leading cause of avoidable surgical errors.
But changing operating room culture doesn’t happen easily, or overnight. Improving communication, collaboration, and teamwork between physicians, nurses, staff and patients, is critical.
What Can We Do to Improve Patient Safety?
Are there current medical training methods available that can effectively improve patient safety and patient care quality?
As a result, when straightforward techniques used routinely in the cockpit like pre-flight briefings, checklists, the ability to call a ‘time-out’, and routine debriefs are used in the healthcare arena, error rates go down.
With continual advances in technology and equipment, surgeons and physicians can’t know everything. Consequently, the importance of teamwork, collaboration, and communication across the entire medical organization cannot be overstated. It takes an entire high performing team to be successful.
Nonetheless, Patient Safety needn’t be a victim of this sophisticated, volatile environment. Nor should your family member, or mine…
Carey Lohrenz is an inspirational patient safety speaker, and advocate whose passion for improving patient safety, patient outcomes and staff satisfaction in the fast-paced field of healthcare brings results. For more ways to improve your teams ability to function effectively see Fearless Leadership, a WSJ Bestseller.