The following letter to the editor written by Meera Kelley, vice president of quality and patient safety, appeared in today’s News & Observer.
Hospitals and a culture of safety
Today’s health care involves numerous specialists, tests, procedures, support services and electronic systems. In this complexity lies the reason for many of the medical mistakes discussed in the Jan. 20 “Harmed in the hospital” Point of View article by James Bryan, M.D., and Burton Craige.
Electronic solutions can help prevent errors, but they can, if we are not watching carefully, introduce new types of errors. Ultimately medical error prevention lies in culture change.
Health care professionals take great pride in what they do, but often they work autonomously. And these physicians, nurses and support staff are human and humans are not perfect. Mistakes in health care have historically been treated as personal failures punishable by job loss.
Rather than expecting perfection, we must design systems that prevent errors from getting to patients, and the most important resource we have for designing safer systems is the experience of those individuals providing care every day. Caregivers must be able to come forward and say, “I made a mistake. Here’s what happened. How can we make sure no one else can make the same mistake?” We can also learn from our much more numerous “good catches” such as “I almost gave this patient the wrong medication when I picked up the one next to it that appeared very similar. In the future we need to make sure to label the medications differently to avoid that mistake.”
At WakeMed, and in many hospitals today, we are striving to support a culture where physicians and staff feel safe and supported in acknowledging their humanness by coming forward and reporting a mistake or a near miss, so we can all work together to improve our systems. We hold individuals accountable if they knowingly take shortcuts or risks, and when we identify an error, we come forward and share that with the patient and family, explaining what happened and what we are doing to help them and to make sure it doesn’t happen again.
Moving toward highly reliable, safe care in such a complex and constant environment is challenging, and improvements to date have been inadequate. It is through 1) striving every day as professionals and as organizations to do our best, yet to be honest about our mistakes, 2) implementing safer systems, working together across health care settings, and 3) changing our culture that we will transform health care into the safe, effective and efficient system it must become.
Meera Kelley, M.D.
Vice President, Quality and Patient Safety
WakeMed Health & Hospitals