It’s no secret that hospitals can be unsafe places. It is reported that every year in the U.S. 200,000 people die from hospital acquired medical errors or infections. That means that a patient is 33,000 times more likely to die from hospital acquired harm than in a plane crash. This is unacceptable and Saint Francis is doing something about it.
At the core of our calling is to ‘First do no Harm.’ Every physician I’ve met over the past 20 years adheres to this professional mantra. We want to help, not harm, our patients. We carefully consider our treatment decisions. Sometimes ruminating about our choices, especially if the outcome for our patient was not what we had intended. We do inform our patients of the potential for harm as a result of our interventions, but all of us hope for and fully intend to avoid them.
We own these individual patient risks as physicians. But we are embedded in a system, and the system imposes its own challenges and risks upon us and our patients. Astute clinicians and administrative leaders recognize that system errors and inefficiencies lead to harm, not necessarily the decisions or actions of any one individual. Other industries have acknowledged this reality and have been working to find and fix these errors for decades. These include the aviation and nuclear energy industries as well as the U.S. military. The result has been a remarkable reduction in deathly errors and the emergence of high reliability science. What has been learned in these other industries can be translated into health care. The results will be safer care.
With the help of CHI, Saint Francis Medical Center is one year into a cultural transformation that is being fueled by high reliability science branded as “SafetyFirst.” All Saint Francis employees have undergone initial training and have begun to use numerous safety techniques to help create a culture of safety. We have already seen a reduction in common errors as a result. For example, the near elimination of mislabeled specimens and the elimination of orphan EKG’s. The newly created SafetyFirst infrastructure, data collection, and analysis has provided insights to our global care that we did not have access to before. After reviewing three years of incidences, a top ten list of common process challenges has been identified. Teams are actively working to fix these process weaknesses. We are learning and patient care is improving.
Physician awareness and participation is critical to the ultimate success of this cultural change. Without us, the transformation will be incomplete, and patients will suffer harm. With us, the organization will continue on its journey to truly exceptional care, and our patients will reap the reward.
This month there will be two opportunities for physicians and providers to obtain CME credit for learning more about high reliability science – SafetyFirst. Additionally, if unable to attend in person, a video recording is available for viewing.
In my opinion SafetyFirst is an excellent example of where the three major ‘tribes’ of health care – nursing, administration, and physicians – are drawn together by our passionately shared and common goal of taking exceptionally good care of patients. While we each come to the table from different and valuable perspectives, we unite together to first, do no harm.