We read a lot about creating a culture of innovation. Given the prevalence of medical errors, we should be equally concerned about creating a culture of safety.
We read a lot about creating a culture of innovation. Some have described a culture as the things people do when no one is looking. Culture describes the result of strategy, structure, people, and processes that create a social norm.
Did you know that 10% of polled surgeons admitted to making a major medical error in the past three months? Did you know that the single biggest cause of medical errors are hand-off communications mistakes? Did you know that it has been estimated that 50% of surgical errors are preventable? In short, we should be as concerned about creating a culture of safety as we are about creating a culture of innovation.
But, how do we do that? Many surgical organizations have started to take notice. Here are some questions to ask about your place that might help:
1. Is there a clear strategy from both bottom-up and top-down to create a culture of safety? If not, what do you need to do to get started?
2. Is there a Chief Safety Officer where the buck stops?
3. Do you have a Safety Management and Reporting System in place?
4. Do you have staff and a data analyst who can identify patterns or events and near misses and can create user friendly dashboards?
HINT: Patterns of near misses are the low hanging fruit.
5. How are you training perioperative teams in safety?
6. How are you eliminating the things that lead to preventable errors?
7. How are you eliminating the “bad apple” mentality in surgical education and training, while at the same time not relieving
personnel of personal responsibility to adhere to safety standards?
8. The two biggest causes of preventable surgical errors are lack of teamwork and lack of communications. What are you doing to minimize team dysfunction and hand-off and communications errors?
9. How are you using information derived from safety management systems to drive behavior change?
10. What can you learn from other industries like aerospace, the manufacturing industry, mining, agriculture, the nuclear power industry, and the military when it comes to safety training and error mitigation?
Judging from the numbers, it is more dangerous to put on a scrub suit than a space suit. There are many opportunities for physician medical practice and process entrepreneurs to make us all safer when we walk through the doors of one of those US News and World Reports’ “Best Hospitals in America.”