By Evan M. Benjamin, MD, MS, and Meghan Long, MHA
Illustrated by Courtney Staples
As we gear up for the Boston Marathon, one of the world’s best known road races, we are also marking Patient Safety Awareness Week. This celebrated 26-mile race next month is a testament to commitment, dedication and persistence in the face of obstacles. Those same qualities lie at the heart of the most successful patient safety efforts worldwide.
The patient safety movement was sparked by a series of reports in the 1990s by Lucian Leape and Don Berwick, culminating in the 1999 Institute of Medicine Report, To Err is Human. These reports revealed shocking rates of patient harm and medical error. As a result, healthcare organizations, government agencies, and researchers began to study safety principles to understand the underlying cause of this public health issue.
When patients and families place their lives and health in our hands, our first priority is to protect them from harm.
The patient safety movement reflects a commitment providers make to deliver excellence in care. When patients and families place their lives and health in our hands, our first priority is to protect them from harm.
Excellence in care must be free from error and needless suffering, effective and scientifically based, customized to the patient’s preferences, without unwanted delays, efficient without excessive interventions, and equitable for all. The first step to driving patient safety is to understand the interconnectedness of these tenets.
Over the past two decades, leaders within the field have contributed a wealth of research on patient safety. Lessons were gleaned from aviation and other industries stressing the importance of adopting principles of high reliability such as having preoccupation with failure.
James Reason, highlighted the importance of a “just culture,” a non-punitive atmosphere encouraging and rewarding transparency at all levels. Other thought leaders highlighted the need for leadership engagement, at the highest level.
Our own organization, Ariadne Labs, has been teaching teamwork and using simple reliable tools to promote patient safety.
Ariadne Labs has led the global effort to standardize safety measures in operating rooms through the development of the Surgical Safety Checklist. At critical surgical points, the checklist encourages preparation, communication, and adherence to important practices that reduce errors and help surgical teams work together better. By using the checklist to build effective communication and teamwork, surgical teams can minimize the most common and avoidable risks endangering the lives and well-being of their patients.
Similarly, Ariadne Labs has been working to improve safety as organizations expand into health systems. Mergers, acquisitions, and affiliations can lead to unintended harm to patients if adequate planning and communication does not occur. Ariadne Labs has developed a set of tools to guide health system leaders through a communication process that uncovers important patient safety considerations.
…Improving patient safety is never about one one intervention, but rather, a culture that integrates numerous interventions and practices that together lead to safer healthcare.
Organizations across the country are increasingly making patient safety a priority. Institutions have appointed Chief Quality Officers, learned how to understand the role of systems, use modern tools of quality improvement and process analysis, and have trained thousands on reliability principles. When we talk to these leaders, they tell us that improving patient safety is never about one one intervention, but rather, a culture that integrates numerous interventions and practices that together lead to safer healthcare.
Like crossing a marathon finish line, organizations invested in patient safety know the feeling of victory. Their medals of honor are decreased hospital infections, lower death rates, or fewer surgical errors. However, just as quickly as an organization can hit its stride, things can still go wrong. Hand hygiene compliance might wane, there may be an uptick in patient falls, and surgical staff may skip surgical time-outs.
This week we want to underscore the importance of patient safety and remember the runners on Heartbreak Hill: Patient safety is a marathon, not a sprint.
Mile 20 is when Boston marathoners often report feeling defeated. This race marker is known as Heartbreak Hill, a steady climb in the hills of Newton that reaches 263 feet above sea level. Often, when organizations feel defeated by their patient safety efforts, it is easy to submit to failure. In our ever-evolving healthcare environment, there are many other initiatives to focus on. This week we want to underscore the importance of patient safety and remember the runners on Heartbreak Hill: Patient safety is a marathon, not a sprint.
Some runners take on the marathon to see if they can beat their best time, others seek to honor the 2013 marathon bombing or the memory of loved ones, while some runners are in it for personal growth. When feeling discouraged by patient safety, it is important to remember why, as clinicians, we care about patient safety — to provide the best care for our patients. When we hit mile 20, we must remember that getting to the finish line of zero defects is a marathon and we must stay focused, train our new colleagues, and know this is the journey of always getting better.
Evan M. Benjamin, MD, MS, is the chief medical officer at Ariadne Labs and Meghan Long, MHA is the project manager for the Office of the CMO.