Sunday, 17 of December of 2017

Every Day is Patient Safety Awareness Week

March 8-14, 2015 is Patient Safety Awareness Week.

Which, if you stop and think about it, is something we should be aware of every day of our lives.

After all, the ability to provide care safely is one of the three core competencies of all clinicians. I say “three” because patients require three things from their healers…

  1. Make me well (medical expertise)
  2. Don’t harm me while making me well (patient safety)
  3. Treat me like a human being (patient experience)

If we can’t ensure number 2, it probably doesn’t matter if we can do numbers 1 and 3. So patient safety awareness is a 365/24/7 responsibility. Given its importance to every clinician and their patients, it’s a good thing to give patient safety a bit of extra focus this week – with the goal of ending the week being better at the skill of patient safety than when you started the week.

Here are 7 suggestions to get you started to make the most out this week:

  1. Find out how many cases of patient harm have occurred in your unit/organization in the past year. Not the rate. Rather, the actual number of instances of harm. This step is to remind you of the work that needs to be done, and the need to get better.
  2. Remember that the primary root cause of most patient harm events is a breakdown in teamwork and communication. Ask yourself, “What one aspect of teamwork and communication will I get better at this week?” Develop one new communication habit this week – something like asking for read backs.
  3. In approximately 80% of every root cause analysis of a sentinel event I have seen it is clear that a member of the healthcare team chose not to speak up when they perceived a problem with patient care. This week, practice breaking down the barriers to communication by making an explicit request of those you work with to “speak up if you see something amiss. Say it early and often.
  4. Find out your unit’s score, from the AHRQ safety climate survey, on the willingness of your team to speak up. Pick one thing you can do to raise this score. (See item #3.)
  5. Say, “Thank You,” to at least one of the staff and/or committee members that work every day to provide safe care.
  6. Add one safety-focused comment this week to any meeting, huddle, shift briefing, or hand-off in which you participate.
  7. Distribute to your team at least one safety-focused article. Pick one thing from the article that you can emulate, copy, or do yourself.

Be better next Friday than you are today. Your patients deserve it.


A Worthwhile Habit

Commit to articulating your point of view on patient safety. Every patient. Every day.

Speak your truth and your perspective with someone who needs to hear it.

Speak up. Not just today and tomorrow, but every day.

That’s a worthwhile habit.

Unkind Cuts, and How to Stop them


…the number of times a week a surgical team leaves a foreign object such as a sponge or towel inside a patient’s body after surgery.



…the number of times a week a surgical team performs the wrong procedure on a patient.



…the number of time a week a surgical team operates on the wrong site.

If you need a tool to assess your facility’s surgical safety checklists, please click on this link.

This tool will tell you exactly where your checklist design and execution needs to be improved.

Here are some questions this tool will help you answer about the checklists you use in your organization:

1. Who should design the checklists you’re using?

2. How many items should be on your checklist?

3. Should checklists be done from memory?

4. Who should lead or run the checklist?

5. How many team members should have a speaking part on your checklist?

6. How can you get more engagement and mindfulness on your checklist?

7. How scripted should you make the checklist language?

8. Should you have tick boxes on your checklist?

Answer these and other questions to find out if your checklist is really effective at preventing patient harm.

Do it today—your patients’ lives depend on it.


Should Physicians Attend TeamSTEPPS Training?

When it comes to TeamSTEPPS training, what physicians want is…

  • Just the 10-minute overview because “I don’t have time to sit through 4 hours of training.”
  • A quick recap of the TeamSTEPPS principles because “This stuff doesn’t really apply to me… it’s really for nurses.”

Giving them what they want  isn’t nearly as powerful as teaching them what they need.

There’s always the temptation to take the available shortcut and just “do TeamSTEPPS for nurses.”

Or you can dig in, take your time and invest in a process that helps people see what they truly need. At LifeWings, we insist on interdisciplinary TeamSTEPPS training with our partner hospitals. We work very  hard on convincing the hospital’s physicians that this training is a worthwhile investment on their part in having better teams to work with, and better teams to support their practice in the hospital.

Yes, we could teach physicians the principles of TeamSTEPPS in 10 minutes. But that wouldn’t make them a better team leader, or give them a better team to work with. To create a better team, we need the quarterback to practice with the team.

In the end, the gains in efficiency and reduction in rework, confusion, communication breakdowns, and wasted effort will save them far more time in a year than they invested in the training session.

Yes, convincing physicians of their return on investment for TeamSTEPPS training can be slow going. But it can be done. If it were easy, every physician would have attended TeamSTEPPS training already.

The Power of a Scorecard

Scorecards drive better performance.

The evidence is clear that solid feedback in the form of a measurement scorecard enhances performance—at all levels and across all organizational units. When people people and groups throughout an enterprise know how they are doing and what needs improving, they do better.

Want to do better? Create and transparently share with your staff a scorecard of the key metrics that define success in your healthcare organization.

Here is an example of what I mean by “scorecard.” It’s called the Patient Harm Index (PHI).

Created in collaboration with a major health care system, the PHI gives the system’s executives a quick way to gauge the safety of its numerous hospitals and clinics.

Typically, health care leaders must mine through volumes of data to get an accurate view of how their teams—and crucially, their significant investments—are performing.  To fix this, we devised a key performance indicator—one simple number—that would enable any hospital CEO, CFO, or Chief Quality Officer in the system, and any individual staff member to—in an instant—know if they are “winning” at their improvement efforts. After working with more than 150 health care organizations, I know that in the end, a simple scorecard makes the meaning of success tangible for the people in your organization.When the results of your effort are tangible, you do better.

I am completely convinced that using a simple tool like the PHI will enable organizations to reach more patient safety successes in 2015.

The tool, available for free at, includes instructions, an Excel template, and an example currently in use at a major health care system.

Measure it. Share the measure. Do better. Pretty simple, really.

What if Patient Safety Were Your Only Job?

You have competing priorities and your organization, and your role in it,  has grown. Maybe patient safety isn’t the most important thing on your agenda any more…

However, the person with your role in the competing hospital across town might actually act like patient safety is their only job. They might believe that treating their patients as if they’re worth the effort in patient safety is the only way to go. They may believe that fixing the medication reconciliation process, or improving the culture in the OR, or taking one extra moment to look a patient in the eye and talking to her with respect as you explain your safety processes is worth it.

We don’t become mediocre all at once, and we rarely do it on purpose. Instead, we start believing that our job is bigger than it used to be, and that patient safety is not the “thing” it used to be, the one thing we used to do so brilliantly.

Patients don’t care about your new priorities. They want to be made well. They want to be treated like a human. They don’t want you to hurt them.

You can’t accomplish the patient’s “triple aim” by doing what you used to do, but less well.

Make exhaustive lists for patient safety breakthroughs

When you “hit the wall” in your patient safety project, or when the work you’re doing is just not good enough to get the results you want, make an exhaustive list to help you get innovative and BREAK THROUGH THE WALL.

Here are some examples of what I mean…

  • Every complaint someone has raised about your project
  • Every method you can use to publicize what you’ve accomplished so far
  • Every time your project and the behaviors needed for success has ever been rejected and what it has cost your patients
  • Every successful project like this that you’ve ever heard about, and why it was successful
  • Every person you know who might help you reach the person on your staff on in your unit who can help you make this a success
  • Every reason your current project might not work
  • Every person you’ve ever met who would be perfect for helping make this a success
  • Every person who deserves a thank you note for supporting you in making your patient safety project a success
  • Every reason you can think of for staff to use the tools or processes you’ve created for safety
  • Every successful patient safety initiative within your city

The challenge of every is that it’s exhausting. You have to go to the edges, and that act, the act of going beyond the obvious, is where innovation lies. the problem of course is that most of us are not willing to spend the time and effort to go there. But your patients deserve it.

The magic of taking ownership of your patient safety work

We used to live in an industrial age, a Smithian-Marxist world where the worker sought to do as little as possible and the boss tried to get the worker to do as much as possible. In this economy, though, that’s just not true. There are all sorts of roads to take in how you see your work, but the most effective, the ones with the biggest payoff that make the biggest dent in your little slice of the universe are the roads where you supply your own locomotion for the work you do.

Patient safety matters. Your work matters. The results you get matter. To you, your hospital, and most of all – to your patients.

The magic of taking ownership of your own patient safety work, is that instead of your work benefitting your CEO, and his salary and bonuses, your work and your learning around improving patient safety benefits you and the people you care about – your patients.

You don’t need more time, you just need to decide.

Willie Nelson wrote three hit songs in one day. What patient safety process are you improving today? You don't need more time, you just need to decide. Get moving.

Typically, it takes about six to nine months for a hospital to decide if it wants to do training to improve the communications between its physicians and nurses. Nine months from the time the executive team and Board of Trustees has decided that it can not  allow any more sentinel events in its hospital.

One hospital I worked with had a series of several serious wrong surgeries. After the third one, and in desperation they called me, asking for an immediate call back. They knew their culture was broken. They knew their checklists weren’t being used correctly, if at all.

It took over 24 months for them to decide to take the steps to fix it.

You don’t need more time, you just need to decide.

Read the history of the original Mac and you’ll be amazed at just how fast it got done. Willie Nelson wrote three hit songs in one day. To save the first brand Seth Godin was responsible for, he redesigned five products in less than a day. Seth says It takes a team of six people at Lays potato chips a year to do one product redesign.

The urgent dynamic in patient safety is to ask for signoffs from your executive team and to push forward, relentlessly.

Keep telling your leaders, “I can make this happen. I’ve got it.”

Seth Godin, one of the best project innovators out there says you can feel this relentless move forward happening when you’re around it. “It’s a special sort of teamwork, a confident desperation… not the desperation of hopelessness, but the desperate effort that comes from being hopeful.”

Your patients are hopeful that you are relentlessly improving how you provide care. Are you?

What’s happening in your unit?

If hospitals were like the Boeing 787 Dreamliner

The Dreamliner has been grounded for several months due to safety incidents with its batteries. The news media has provided in-depth coverage of the story. One film clip that made the news was of female voice of the Boston-based air traffic controller telling the pilot of the Japan Airlines 787 that he must stop at the end of the runway; she is sending emergency vehicles out to deal with the fuel leak. She doesn’t have to argue, the conversation is calm, clear and concise, and the plane stops with no argument or discussion. Both the pilot and the ATC controller are personally accountable for what happens to the aircraft and its passengers.

Here’s what Richard Corder on the blog KevinMD has to say about that incident…

“In our hospitals, these “incidents”, these “near misses” rarely get reported internally; the associated press and the national evening news certainly don’t pick them up as front page stories.

If we are obsessed with safety, like the human factors focused airline industry, our near misses and our good catches would be enough for us to stop the line, stand back and work to develop safer systems.

I know that the analogy is not perfect, our clinicians and care givers are tending to the complex human system that we cannot treat like the machine that is a plane, that being said there are lessons to be learned.

So what can leaders do?

Lead a culture where you model that it is safe to speak up and encourage people to call out near misses, report good catches and model the mindset and actions of being personally accountable.

Make it known that while clear roles and clarity around authority are important, everyone is personally empowered to speak up or call an unsafe or potentially unsafe behavior to the attention of their colleagues.

Use all meetings, from the board to the bedside, to tell stories of how a mistake was avoided and how, when things go wrong, you recovered.

When things do go wrong because they will, we are human beings caring for human beings, don’t point fingers and blame people. Own the outcome, work to learn from the failure, apologize, atone and remain open to feedback.

Adopt some of the human error mitigation systems that the airlines have embraced.”

Richard is right on the money with his comments.