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Leadership Blog

Patient Safety: It’s More Than Technology and Checklists

By Liz Youngblood, RN, MBA, FACHE, President, Baylor St. Luke's Medical Center, and SVP/COO St. Luke’s Health Texas Division

August 14, 2023 Posted in: Leadership

When patients go to receive health care services, they expect the process to be safe, and it should be. We owe every patient we see safe care—and we owe our employees a safe workplace. But doctors, nurses, and other staff are human, and humans can make mistakes. That doesn’t excuse medical errors, but it definitely makes it crucial for health care organizations to have a robust patient safety program in place to help prevent them. Creating and nourishing a strong culture of patient safety is a key component.

Patient Safety Affects Many

In the U.S., between 160,000 to 200,000 hospital patients die annually from accidents, errors or infections, many of them preventable. The World Health Organization estimates 1 in 10 people in high-income countries are harmed while receiving hospital care, including the U.S., and that half of those injuries are preventable. 

Although statistics have improved since the landmark 1999 study from the Institute of Medicine, “To Err is Human: Building a Safer Health System,” the Centers for Medicare and Medicaid Services still penalizes hundreds of hospitals every year for low patient safety scores.

Understanding the Problem  

Every hospital is different, but according to a 2022 report from the Office of Inspector General for the U.S. Department of Health and Human Services, the majority of adverse events occur in four areas: 

  • Medication errors: The report found 43 percent of Medicare patients who experienced patient harm in a hospital had an adverse event related to medication. Delirium and hypotension were the two most common events, often due to improper opioid dosing. Kidney injury and excessive bleeding were also common.

  • Failures in patient care: Another 23 percent of events involved harm related to daily care. Common problems included pressure injuries, skin tears, falls and issues with IVs and catheters.

  • Surgical complications: Around 22 percent of events occurred following surgeries or procedures. Complications included hypotension, issues with anesthesia, excessive bleeding and embolisms.

  • Infections: Just 11 percent of adverse events were caused by hospital-acquired respiratory infections, surgical site infections, thrush and sepsis.

The report determined 43 percent of these adverse events were preventable.

Why Mistakes Happen

Errors can happen for many reasons. Hospitals get busy and staff can get distracted. New graduates can become overwhelmed. Maybe someone is tired at the end of a long shift. Or maybe there’s a communication breakdown between clinicians.

Many tools need to be in place to prevent mistakes from happening, including patient identifiers, checklists, electronic health records, alerts and scanning technologies to ensure medication is correct are just a few examples. Yet even if you build multiple safety steps into the patient care protocol, everyone must actually follow the steps and use the technology for optimum results. Even then it is important to note that technology is a tool, but it doesn’t replace sound clinical judgment. 

Paying attention and understanding the details of what you’re doing is critically important, as is building a culture of safety. Staff should feel comfortable stopping the line and asking for clarification. . For example, if a clinician is about to place an order on a patient for a medication and it isn’t consistent with what another clinician thinks should be ordered, asking for clarification is a good way to engage in a dialogue about the rationale and other potential options. 

Patient Safety Is a Team Effort

It takes everybody involved in patient care to build a strong culture of patient safety. Clinical and non-clinical staff alike should be encouraged to say something if they see something concerning. It’s essential to create a culture where people feel safe and empowered to do that, no matter their role within the organization. 

As health care leaders, we set the example for others, and while that includes utilizing all the available tools and technology to build a safety protocol that helps prevent errors, we must also create a culture that supports our care teams. Whether it’s the tech on the floor or the surgeon in the OR, a strong patient safety environment requires everybody on the team to feel confident  using their voice. That’s a critical component that technology can’t solve. That culture is the piece that will take you from doing a good job to doing a great job with patient safety. 

How St. Luke’s Health Is Improving Patient Safety Outcomes

St. Luke’s Health has worked hard to improve its ongoing patient safety initiatives. Because of this work, infection rates have fallen, and we’ve continued to see progression in all of our indicators. You can see the end result of this work when you look at rankings, including from The Leapfrog Group. 

Our culture ensures that everybody feels like they’re an essential part of the care team, even when they’re not involved with direct patient care. This creates a feeling of unity and teamwork that enables us to provide the best care. A strong culture of patient safety means preventing  siloed staff in which members are apt to say, “That’s not my department, so it’s not my problem.” Nobody wants to hear that, nor does it help address the issue at hand. Refusal to take ownership only increases the risk of making an error. 

Listen to Your People

In addition to ongoing training and assessments to improve patient safety and reduce the risk of preventable injuries, such as falls, we also run a patient safety survey for staff at least twice a year. Not only do we ask questions that help us discover new areas of concern and areas to promote, but we also ask staff, “Do you feel comfortable speaking up?” 

The responses we receive are used to create action plans to address problems. This ensures that we’re constantly talking about patient safety and safe environments. These daily, ongoing conversations are part of St. Luke’s Health’s commitment to a healthier future for all.

What is your hospital doing to create a strong culture of patient safety?

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