Stop the Ride
Protecting patients and staff from errors should be our No.1 priority

By Beth Ulrich, Ed.D, RN, South Central Editor
July 23, 2001

What does your organization value most? If your fellow employees were asked, what would they say is most important? Are they sure, or are they just guessing?

Several years ago, I was privileged to attend a quality workshop at Walt Disney World in which Disney employees talked with participants about quality assurance. Their keys to quality are teaching Disney values to every employee and integrating those values into every policy, procedure and decision. They believe the number of things you really value must be kept small, because if you try to value everything, you value nothing.

They also believe values must be prioritized so that employees are never in doubt as to which is most important. They were emphatic that each employee clearly understand what one thing is most important. Not what two or three or four things are important, but what one thing is valued above everything else. In their case, it is safety.

Yes, they value other things. One Disney value is to produce a total experience for the customer—what they call "the show." Another is efficiency. Safety, however, is No.1.

No employee, they stressed, should ever think twice about intervening if safety is an issue. The example they used was deciding to stop a ride. At Disney World, keeping the rides going is a big deal. When rides aren’t running, the customers aren’t happy. Any employee can stop a ride if he or she believes there’s a safety issue. No calls to the front office. No supervisor’s approval. Just stop the ride.

If they can do it at Disney World, why can’t we do it in hospitals? Why can’t we say without equivocation that safety is our No.1 priority? Better yet, why can’t we mean it if we say it? Individually, we all want safety for ourselves and for our patients, but how often is that safety compromised without someone "stopping the ride?"

Is it safe to admit a patient when you know there aren’t enough nurses, pharmacists, OTs, PTs, etc.? Is it safe to do long operations without giving nurses a break? Is it safe to staff a unit with a nurse who is on her fifth 12-hour shift?

JCAHO standards have a way of forcing issues to the forefront and the new safety standards will make hospitals look at safety issues. Hospitals will have to tell patients when their treatment outcomes vary from the anticipated results.

It’s pretty clear how to do that when an error occurs, but what about when we can predict errors will occur? It seems to me that we have a moral obligation to tell patients when we know we’ve increased the odds of mistakes occurring or of not achieving the desired outcomes.

Imagine what the disclaimer to patients in many short-staffed facilities would sound like: "Sir, we’ll be taking care of you today with fewer nurses than we would like and with one nurse who’s worked a lot this week, so we won’t be able to give you the kind of care you expect or deserve for what you’re paying us. Oh, yes, that does increase the chance that we’ll make some sort of mistake. And we certainly won’t be able to do that discharge teaching that you need to get back to work as you planned. In fact, we’ll do well just to get you your medications and your meals."

We’ve talked about safety for a long time. It’s time to really do something about it. Safety must be our priority every minute of every day, in every policy and procedure and in every decision we make. The only way hospitals become truly safe for both patients and staff is for safety to become our No.1 value—not just on paper and not just the week the JCAHO surveyors are in town.

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