Enhancing Our Culture of Safety

Lately, I’ve been thinking a lot about what it means to have a culture of safety.

With a population of 22,000 employees and more than two million patients, visitors and guests coming through our doors each year, the University of Michigan Health System is a vibrant community unto itself. And in an organization of this size and complexity, things will go wrong, mistakes will be made and accidents will happen. What is most important is how we deal with and learn from our mistakes, problems and accidents to make sure we are always striving to create the safest environment possible.

When I was CEO at Riley Hospital for Children in Indianapolis, I had personal experience with a serious medical error. One night, when I was the Administrator on Call for Clarian (now known as IU Health), I had a chilling experience that forever changed my approach to patient safety.

My husband, Mark and I were at a black tie event when my Blackberry buzzed. The message said: CALL – EMERGENCY. I learned that five vulnerable premature babies in the Methodist Hospital NICU had received a terrible overdose – adult dosages of heparin, a blood-thinner to prevent clotting. The drug’s manufacturer had streamlined packaging to simplify its use, but this caused confusion as to which vials contained adult doses and which contained the much smaller pediatric doses.

I left my husband at the concert and told him to find his own way home, and I rushed to Methodist. On the way, I called the NICU and learned that medication to counteract the heparin had already been given without any noticeable improvement. I knew that meant the situation was terribly serious. I contacted Clarian’s Chief Operating Officer and the system’s Chief Nursing Officer who were attending another black tie event and I told them to meet me at the hospital. Within minutes, the three of us arrived on the unit – all of us dressed in formal evening wear. That alone signaled to staff who saw us running into the hospital that something was terribly wrong.

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I entered the NICU. The unit was nearly full of babies – 26 of them with only one crib unused. Babies were crying. Frantic parents were crying. One mother demanded the names and addresses of specific nurses and vowed revenge on those she believed were in the process of killing her infant. No, I thought, that’s not what happened. This was a medical error, a very serious error, the most serious one I had ever seen.

Questions had to be answered: What exactly had happened? Who was involved? Where were they? How would order and control be restored? What was the best path to care for the affected babies and others in the unit? What about the families? What should I do? What could I do?

Though it was late Saturday night, I called additional neonatology staff at home and asked them to please come in to assist with the crisis. They did so willingly. I spoke with the many chaplains who had arrived to provide support and comfort, and I helped direct them to the frightened and grieving parents and terrified staff. In addition, I asked for a summary of events from the unit’s nurse practitioner and neonatologist. After reviewing the number of adult heparin vials that were missing, contemplating the chaos of the situation and hearing the reports, I had a sudden realization that there must have been a sixth baby who was given a heparin overdose. During the next several minutes, we identified a sixth baby. Care to this child was initiated immediately.

In the end, two babies died within the first 24 hours and a third baby died a few days later; three babies lived, including the sixth one we had identified. The entire institution was changed in perpetuity as a result of this calamity.

See also  Health System Advisory Group

Patient safety became the mantra across every unit at every Clarian/IU Health and I was reminded why it is so important to never be content and to always be improving. No matter how good we think we are, we can always be better.

Creating a culture of safety means many things, including:

  • Admitting our own errors and mistakes when they occur, and feeling empowered and supported to speak up when we see another’s;
  • Respecting each other’s professional input and checking our egos at the door so  that we always remain focused on our number one priority – patient safety;
  • Continuously evaluating our processes and procedures to identify areas for improvement and then implementing these improvements;
  • Engaging patients and families in health care decisions and keeping them informed throughout the course of care;
  • Holding people accountable for their work and their actions;
  • Learning from errors so that we don’t repeat them.

Health care is a human system, and humans are fallible. There is not and never will be a perfect person or a perfect hospital. The most educated, experienced and well-intended people make mistakes, and the most prestigious health care organizations make medical errors. That is why a culture of safety requires processes and systems that minimize human error.

In his book “Complications: A Surgeon’s Notes on an Imperfect Science” Atul Gawande says: … not only do all human beings err, but they err frequently and in predictable, patterned ways. And systems that do not adjust for these realities can end up exacerbating rather than eliminating error.

While it may be impossible to be perfect, we most certainly can be exemplary.

See also  Courage

I am proud of the University of Michigan Health System. But, to be a leader in safety, we must demand excellence from ourselves every single day. Because we can never be perfect, we must be resolute in our commitment to continuous improvement. I know that this Health System has what it takes to be the safest hospital in the nation. I call on all of you to engage, to recognize the important role you play and to be more diligent than ever in pursuit of this foremost goal.