Safety in numbers
By Peter Angood,
MD FRCS(C), FACS, FCCM
Vice President and Chief Patient Safety Officer
The Joint Commission
On average, eight to 10 wrong-site surgeries are reported to The Joint Commission's Sentinel Event Database each month. Educational campaigns and in-depth policies and procedures to encourage compliance with the Universal Protocol have been employed at many organizations to combat these unfortunate incidents.
Sadly, wrong-site surgeries are still occurring. In fact, these medical errors have remained the most commonly reported sentinel event at The Joint Commission for the past three years.
One major reason this problem persists is that patient safety requires a systematic approach to providing optimal care and processes, and for that to occur you need teamwork, strong leadership and buy-in from every individual in the organization who cares for the patient-directly or indirectly. Medical errors are generally not the result of practitioner negligence or a high proportion of bad actors, they are more consistently the result of flawed processes.
As you review the 2009 National Patient Safety Goals and update your facility policies and procedures, remember that the Goals and the Universal Protocol are tools that The Joint Commission provides the healthcare field to help create change. But these are only tools. Real change requires a critical review of care processes, redesign of these systems and ultimately a positive culture of safety that makes it easier to improve patient care.
The Universal Protocol is a wonderful example of how difficult it is to create change in healthcare. On paper, the Universal Protocol seems simple-just follow a series of three easy steps that occur in environments where a limited number of professionals work together on a regular basis. But healthcare professionals know that these seemingly simple steps require coordination of care, effective communication and active participation from every member of the procedure team.
Following a second summit on this topic in 2007, where more than 50 professional organizations participated, the Universal Protocol was revised to create more specific steps organizations will need to implement. Beginning on Jan. 1, 2009, The Joint Commission surveyors will be assessing these steps closely. But, ultimately, the key steps necessary for success when implementing patient safety practices include learning how to work and cooperate as a team, and sharing a focus on what processes are needed to provide the safest, highest quality care.
How can perioperative professionals promote this cultural change?
- Work with administration to gather relevant data from the organization, develop instructive reports from this data, and then educate senior level administration so that they can clearly understand what is working and what isn't working in the organization.
- Identify surgeons who buy-in to patient safety practices like the Universal Protocol and then learn how to collaborate with them-pay special attention to their issues and what they know about the organization. Doing so will create a positive environment and a culture of safety that trickles down to those who may resist.
- Encourage reporting of issues, near-misses and sentinel events because they are the basis of learning and meaningful data provide the evidence needed to build support and create change.
- Create forums where the existing processes are critically reviewed, evaluated and revised so that improvements that work best in the local environment can be promulgated - then monitor and continually reassess the outcomes over time.
Providing safe patient care is a process in itself, which requires continued reinforcement and improvement to ensure the best patient outcomes.
Peter Angood, MD, FRCS(C), FACS, FCCM, a surgeon, is the inaugural chief patient safety officer and a vice president for The Joint Commission. In this role, he oversees the annual development of The Joint Commission's National Patient Safety Goals and other enterprise-wide patient safety initiatives.
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