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Interview
by Leigh Morgan Anne Shea, MBA, RN, has made the most of both her nursing and business degrees by working in a variety of healthcare management and development positions. In 1995, she set up Catholic Homecare, the first home health agency under the jurisdiction of the Archdiocese of Chicago. In September, Shea left the organization to accept her current position as chief operating officer and acting executive director of the National Patient Safety Foundation (NPSF). Sponsored in part by the American Medical Association, the 2-year-old Chicago-based nonprofit strives to measurably improve patient safety. Shea said that she is drawn to the excitement and collaboration that start-up organizations offer, but added that her interest in the NPSF also stems from personal experience. “Patient safety is a concern for me,” Shea said. “Just moving my mother and father along through the healthcare system has at times been a challenge.” Q: What most endangers patient safety? A: Silence and fear. These are a product of the blame-oriented culture that we work and live in, and they keep people from talking about and learning from near misses and mistakes. This affects healthcare professionals as well as patients and family members. At NPSF, we’re always looking for open dialogue. We’re trying to create a culture of trust by bringing the entire range of healthcare professionals together—pharmaceutical houses, nurses, doctors, and different academic groups—to participate in conversations about patient safety. The real tragedy about healthcare errors is that there’s just so little knowledge that’s been derived from them. That leaves the door open for similar errors to reoccur. Q: What’s the most important step health professionals can take to improve patient safety? A: I think it’s really about sharing and analyzing our stories. When we talk to each other about our errors and successes, we can begin to understand the technological, organizational, and behavioral loopholes that lead to errors. If we can gather enough information to recognize patterns, then we can plan better systems to prevent them. NPSF brings a lot of stakeholders to the table to have open conversations about this, and we focus on the ways hospitals and other healthcare organizations can improve patient safety on a daily basis. We’re looking at doing a solutions conference next fall and designing an awards program so nurses and allied healthcare professionals from the field have a forum for coming up with some very practical problem-solving techniques. Q: What role do RNs play in ensuring patient safety? A: RNs are case managers, really, and I think overseeing every aspect of a patient’s care and understanding how each member of the healthcare team fits into the overall picture is key. This perspective enables nurses to recognize opportunities for risk and error. In home care, nurses I’ve worked with would occasionally notice that medications were mislabeled. Nurses often have a unique opportunity to spot such potentially dangerous errors and to prevent and correct them. Q: What would you like to see in the future to improve patient safety? A: I would like to see nursing forums, where nurses would get together as a group to share their stories. There are barriers to that within the current system, however, such as skeleton staffing patterns. Nurses are so busy, and a lack of time prevents them from sharing their stories and increases the chance of making mistakes. We also have to find out if such forums exist. If not, who would set them up? Would they begin as a grassroots effort involving staff nurses or as an administrative effort? We’re now in the process of trying to answer these questions. |
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