13 wrong-site surgeries, one on the wrong person, and she has questions

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The 2016 Connecticut Department of Public Health Report on adverse medical events was recently released.  I was waiting for this report and hoping that I would read about significant improvements from the past years, showing meaningful reductions in the number of patient harm events leading to death or serious injury or consequences.

What I read was that there has been no significant reduction in the number of patient harm events over the last year.

More noticeable to me was that when I looked at the individual items, some of them simply should not be occurring!  How is it that there were 13 wrong site surgeries, one wrong surgical procedure performed on a patient and even one wrong patient surgery?  With the use of high reliability strategies and the other tools being employed by our hospitals and other health care providers we must ask what is missing, what can we do differently?

Part of the adverse event codes from the state Department of Health report.

Part of the adverse event count from the state Department of Health report.

I have to wonder if enough is being done to truly change the patient safety culture within our hospitals and health care facilities.  Is there a just culture where everyone within these facilities feels free to speak up when they see things that could be done differently or, even more importantly, when they see something being done incorrectly?

While individual responsibility and accountability must be held to the highest standards, are our systems still functioning in a punitive way or are they using every possible opportunity as a learning or teaching moment?  And are our systems really person-centered or are they really just person-focused?   Is health care being provided with patients’ full involvement or is it only being done for patients and with their best interest in mind as perceived by health care providers?

In our hospitals, is rounding consistently occurring at the bedside with the full involvement of the patient or is it occurring outside the door or even at the bedside but with everyone discussing the patient in front of them but not with them?  To have full patient engagement, it must be asked why patients still don’t have access to their actual medical records in real-time and have to deal with all kinds of administrative “hoops” to get them.  Wouldn’t it lead to better care if patients could read their medical records in a timely way, both for accuracy and to allow them to be fully engaged in their own health care?

Leadership comes from the top.  Change comes when everyone is invested in the change, believes in the change and is motivated to change.  Everyone involved in healthcare should examine where the focus is being placed.  It has been shown that when the focus is placed on the real goal (patient safety) and not on a perceived goal (patient satisfaction scores), on a patient safety culture with top-down leadership, our hospitals and other health care providers more successfully achieve a reduction of healthcare harm and at the same time see improved patient satisfaction and health care outcomes.

Maintaining the status quo is not acceptable.

Lisa Freeman is Executive Director of the Connecticut Center for Patient Safety.

What do you think?

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