Patient Safety Requires Discipline
By Andre Harris, MD, chief medical officer, Miami Valley Hospitals, Premier Health
How many times have you driven to work and suddenly realized you do not remember part of the trip? An autopilot-like muscle memory takes over as you follow a route you have traveled hundreds or even thousands of times. The same phenomenon can occur in healthcare. We go through familiar routines, setting up for a procedure or caring for a patient, when a distraction interrupts the process. A missed step or overlooked detail can turn a routine situation into a difficult outcome for both the provider and, more importantly, the patient.
Patient safety requires deliberate focus. It demands that we check and recheck our work because, unlike a defective widget on an assembly line that can simply be discarded, the consequences of our errors can result in real patient harm, morbidity or even mortality. “To Err Is Human reminds us that mistakes happen, but the question remains: How much of that error is preventable?”
As I discussed in my last column, a preoccupation with failure is a prerequisite for prevention. Organizations that continuously improve are those that remain curious about what could go wrong before it actually does. As we deepen our process improvement efforts at Premier Health, it will require a different level of curiosity from all of us. This is the type of curiosity that does not avoid complications or near misses but instead seeks to understand them. Our Just Culture framework supports the reporting of both near misses and actual events because every report represents an opportunity to learn and improve.
No patient enters the healthcare system expecting to be harmed. Likewise, no healthcare provider begins the day hoping to experience a complication that causes injury. Preventing harm depends on two things: reliable systems and disciplined attention to detail.
One of the commitments outlined in our Compass is safety. First and foremost, that commitment is to our patients. However, safety also has a profound impact on our caregivers. The emotional toll that follows a patient complication can affect a healthcare professional for years. When we build safer systems and practice disciplined care, we protect both those we serve and those who serve.
As we continue our journey toward becoming a highly reliable organization, I ask each of you to make patient safety a deliberate practice every day. Slow down when something does not seem right. Speak up when you identify a risk. Report near misses and complications so we can learn from them. Challenge assumptions, ask questions and remain curious about how we can improve. Every checklist completed, every concern voiced and every detail double-checked is an opportunity to prevent harm.
The expectation is simple: Be present, be disciplined and be curious. Our patients are counting on it.
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