Home Column Insuring patient safety: a ‘workplace of accountability’

Insuring patient safety: a ‘workplace of accountability’


Those of us fortunate to work in the medical profession realize the great privilege bestowed upon us. Patients come to us and literally put their lives in our hands. They allow us to run tests, examine, probe, and at times even cut into their bodies. We provide them medications, therapies, advice and say, “Trust us.”

Yet despite our best efforts, we often fail. I wish I could say this is a new problem. It is not.

In 1999, a report titled, “To Err is Human,” was published by the Institute of Medicine (IOM), which estimated that between 44,000 and 98,000 people were dying each year in U.S. hospitals as a result of preventable harm – the key word being “preventable.” I remember questioning the report’s validity. These numbers must be wrong, I thought.

The numbers were wrong. But not for being too high but sadly, too low. Subsequent studies revealed the numbers are actually far beyond 98,000 deaths per year. In fact, a recent study published in the British Medical Journal estimated the number to be over 250,000 deaths per year – about 700 per day. This would place medical harm as the third leading cause of death in the U.S. behind cancer and heart disease.

However, these findings should not be an indictment of our health care workforce. The work done every day in U.S. hospitals by professional caregivers is exceptional. What we called medical miracles a few years ago, such as organ transplants, are commonplace today.

The IOM report was a call to action. Following its publication, new models offering best practice standards emerged and organizations supporting patient safety excellence and oversight came into existence.

I practice medicine within the Yale New Haven Health System and specifically at Greenwich Hospital. While our organization is already recognized as a top-level provider of safe care, we are committed to becoming a national model of safety excellence. Safe practice is not just for doctors, nurses, technologists, and so forth. It is everyone’s responsibility.

Historically, health care has been intolerant of human error and even punitive, especially if an error results in patient harm. The expectation has been make no mistakes, ever!

The reality of being human, however, is that we all make mistakes. It is not a matter of how smart or how caring we are. It is a matter of simply being human. We are all fallible. Error is random and unplanned. Yes, errors can be reduced and mitigated but never completely eliminated.

Those of us in the medical profession have seen and heard stories about the nurse fired for giving the wrong medication, a surgeon sanctioned for an error in the operating room, an X-ray technician suspended for taking the wrong film, or the pharmacist sent to jail for failing to properly verify a medication.

This punitive approach has done little to reduce errors and, it can be argued, has made health care less safe. When possible, people will choose to hide the error to avoid reprimand and punishment. The tragic consequence is there is no learning.

Our organization is committed to reducing error as much as possible and mitigating harm, but we realize that staff will occasionally make an unintentional error. We have chosen to create an environment where employees can raise their voices or report an error without fear of reprimand, knowing they will be supported – a fair and just culture.

This approach has been criticized by some as too lenient, for lettingcareless” people off the hook for their mistakes. Nothing could be further from the truth.

This model centered around learning in an open, fair and just culture is called a “Workplace of Accountability.” It works only if we provide all our employees with the tools and knowledge they need to produce reliable outcomes.

An example of how we have applied high reliability in our organization is a daily safety huddle every morning, every day of the year. Leaders and representatives from each area gather to share significant safety issues from the prior 24 hours and look ahead to anticipate any concerns for the next 24 hours. Also embedded across our organization are dozens of highly trained safety coaches who act as a local resource.

Our CEO and high-level administrative staff come around often, seeking to promote safety and reinforce a culture of openness. The goal is to meet as many staff as possible over the year. Staff are encouraged to share concerns, big or small, and these concerns are addressed.

Employees are recognized and celebrated for their efforts in finding ways to make our organization safer, and we share stories as a learning tool for safety.

These efforts have generated positive results:

  • Greenwich Hospital was awarded a top Grade A for patient safety from a survey of over 2,500 U.S. hospitals conducted by the LeapFrog Group, a nonprofit organization dedicated to the highest standards of safety and quality across the U.S.
  • The Agency for Healthcare Reporting and Quality conducts annual surveys across hundreds of hospitals to evaluate staff perception of safety. The scores for our organization have far exceeded the national average, and most recently scored in the top quartile of the country in almost every domain of safety.
  • Since embracing a fair and just culture in conjunction with high-reliability training, we have seen a reduction in serious safety events of over 80 percent.

A question we often ask our staff is, “Would you feel safe having yourself or a loved one cared for here?”

The answer is almost always “Yes,” but most revealing is the big honest smile that accompanies the answer – and that is both a favorable and reliable outcome.

Dr. Stephen G. Jones is medical director of safety for Yale New Haven Health System and on the staff of Greenwich Hospital as director of the Outpatient Center for Healthy Aging. This opinion piece was based on a talk delivered at the Westchester Medical Center.

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