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How We Learn to Avoid Mistakes

August 13, 2013

Every day our patients are at the center of near miss events.  Recently we had a near miss medical event at one of our hospitals.  A patient nearly had the wrong procedure performed in the Operating Room.  The staff was incredulous that this could happen here.  Subsequently, we’ve studied the care and the circumstances surrounding this and now have a better understanding of what happened in this case.  These lessons have been integrated into the care model to avoid a repeat occurrence and improve safety in our care processes.


When we investigate the root causes after a serious medical event, we often learn that there were precursor events and warnings that should have signaled to us that something was wrong; that a significant event was inevitable.  Sometimes these warnings come from our staff, but often they come from our patients.  In this case, we learned that the patient questioned different staff on a discrepancy on the consent form several times, yet it was not addressed.  We need to learn how to listen to these warnings and how to respond to them so that we learn how to avoid the next medical mistake.  We also need to learn not to fear transparency and actively share our performance with ourselves and others so that we may all learn.


An Ethic of Learning

At Baystate Health, we continue to embrace and support an environment that fosters an ethic of learning.  We need to listen to the voice of our patients when they speak up.  Most complaints are not complaints related to service, but actually complaints that have implications for patient safety:  A patient waiting in the ED, a rushed physician not paying attention, a nurse without enough time to respond to a patient.  As clinical staff, we must create and support learning in all of the areas we work.  If a patient complains, who hears about it? Does it become fodder for sharing at a staff meeting? Is it raised to leadership to improve systems?  Listen to the patient and what you hear are patient safety events that could lead to medical error.


Transparency Improves Care

Transparency of our performance should be complete, timely and unequivocal.  All data on quality and safety should be shared in a timely fashion with all staff.  First, we must share our performance internally, and then in an accessible way with the public.  Improvement work has shown that once we understand where the gaps and the failures are, we will seek to correct the issues.  Sometimes transparency is hard because we tend to personalize the data, yet most of our work is the result of systems and team performance.  As we understand our own performance, we will see the opportunities to improve.


Quality Improvement Science

Mastery of quality and patient safety sciences should be part of initial preparation and lifelong education of all healthcare professionals, including managers.  As a healthcare organization, we must train each other in quality improvement and all of us must seek out the best patient safety practices and apply them to our care processes.  Patient safety needs to be the number one priority, and by understanding the principles of improvement, we can make our system better and safer.


Fortunately we have great clinical and medical staffs.  We have promoted system thinking and transparency throughout our organization, yet while we have few preventable medical events, they still occur.  Through continual learning, active listening, embracing transparency, and applying principles of improvement, I am confident that we will be able to eliminate all preventable events.


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