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The hospital sent Robert Caplan, MD, and Cathie
Furman, RN, MHA, vice president of quality and
compliance, to the congress, where they led a
workshop, “Stopping the Line for Safety:
How to Get Zero Defects in Health Care Quality,”
which described a proactive effort by the medical
center to reduce patient errors. Anyone identifying
a patient safety concern that might cause significant
harm notifies a patient safety team that is on-call
around the clock. The team, including the executive
accountable for the reported area, would immediately
evaluate the “patient safety alert”
and try to prevent the error.
“It’s unique that we make a patient
safety alert a top priority, but that is critical
to the success of this particular program,”
said Charleen Tachibana, RN, MN, chief nursing
officer at Virginia Mason. “It’s also
a strong message to staff that this work is important.”
“It’s critical that the team have
the authority and the accountability to ‘stop
the line’ — that is, remove whatever
is potentially harmful to the patient whether
it’s a product, procedure, or another person,”
Furman said. In one instance, an elevator was
removed from service because the nursing staff
was concerned that it kept breaking down —
with unstable patients inside.
Reporting of patient safety alerts is up 35%,
but that’s not enough, Furman and Tachibana
say. They want to see reports increase to 800
per year so that potentially harmful situations
are detected earlier in the process. “We
want nurses and other staff to increase their
reporting,” Furman said. “We want
them to come forward and tell us what is putting
them in jeopardy due to process breakdown. We’re
starting to fix the things [nurses] deal with
every day that have been frustrating to them for
years.”
Communication is key
As director of risk management and quality assessment
for Beta Healthcare Group in Alamo, Calif., Elaine
Bierman, RN, BS, knows the value of good communication.
A nurse for 34 years, 14 of them in risk management,
she understands how patient safety can be compromised
when communication fails. Bierman also attended
the congress and was interested in a presentation
on the breakdown in communication among the patient,
the caregiver, and the hospital. “Patients,
Family, Clinician Partnerships that Change Culture:
The MITSS Story” was presented by Frederick
van Pelt, MD, and Linda Kenney, a patient who
was undergoing ankle surgery when van Pelt inadvertently
injected nerve block anesthetic into her bloodstream,
causing cardiac arrest.
Kenney recovered, but said at first she was denied
access to anyone who might help her understand
what went wrong. She and van Pelt used their experiences
to help patients like Kenney by founding Medically
Induced Trauma Support Services (www.mitss.org).
“In addition to providing direct emotional
support to patients and families, the mission
of MITSS is to serve as an advocate to increase
awareness of the emotional impact that these events
have on all involved and to promote the development
of coordinated follow-up support,” Kenney
said. “Patients, families, and clinicians
all suffer when adverse events occur and they
need to be taken care of.”
Bierman said that Kenney and van Pelt conveyed
the importance of disclosure and communication
when an adverse event or unanticipated outcome
occurs. “We have yet to know if this type
of disclosure reduces the incidence of malpractice
claims,” she said, it does go a long way
toward helping all parties to the event understand
what each is going through.”
Bierman thinks that a congress like this highlights
practical ways to deal with patient safety. “This
kind of conference helps all of us create a safer
work environment,” she said. “It’s
also motivating to hear speakers who are so committed
to providing safe care and good care to patients.”
What was particularly exciting about this congress,
Ganser said, was the number of organizations and
multidisciplinary teams that came forward to share
their own knowledge and best practices. “Learning
and sharing have become hallmarks of the patient
safety movement,” she said.
Please go to the next page to see the
2004 National Patient Safety
Goals
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