LOOKING UP Your OR staff will see how your facility's leaders prioritize patient safety and follow their example.

Anesthesiologist Kenneth P. Rothfield, MD, MBA, CPPS, can hardly wait to hand $500 to a housekeeper who tells a doctor, "You forgot to wash your hands." Some context: He's referring to a patient-safety award his employer started in 2015. The award grew out of a workplace culture designed to empower and encourage every team member — from the newly hired housekeeper to the longest-tenured surgeon — to speak up if they see something that might contribute to an adverse patient outcome.

Dr. Rothfield points to one statistic as proof that every healthcare organization needs to make the prevention of avoidable errors "not only a priority but the priority": As many as 250,000 Americans die each year as a result of medical errors — the third leading cause of death in the United States, behind only heart disease and cancer, according to the U.S. Centers for Disease Control and Prevention. But how do you go from prioritizing safety to creating a culture? It begins with a commitment from an organization's executive leadership that filters down to the OR in the form of actions staff can see, feel and experience every day.

"There's no substitute for committed leadership that's ready to walk the talk," says Dr. Rothfield, system vice president, chief medical officer and chief quality officer at St. Vincent's Healthcare in Jacksonville, Fla. "If we don't do that for our frontline staff, we run the risk of doing harm to somebody."

One brick at a time
Creating a pervasive culture of safety might sound like a monumental task, especially if you're starting from scratch. So don't try to solve everything at once, says Mark P. Jarrett, MD, MBA, MS, senior vice president and chief quality officer of Northwell Health, a New Hyde Park, N.Y., health system that includes 21 hospitals and 500 ambulatory sites.

"Culture takes a long time to change," says Dr. Jarrett. "To do it effectively, you can't take on a project so it's fixed this week but next week it's broken again. Build a better mousetrap by taking the time to get at the root of the problem."

It could be fine-tuning time outs to prevent a wrong-site surgery. Or analyzing the way you label lab samples to eliminate processing errors. Or reviewing how and where you store medications to decrease the likelihood of administering the wrong look-alike/sound-alike drug. No matter the project, leadership should always involve frontline staff to determine the most appropriate course of action.

"You can't do it by yourself," says Dr. Jarrett. "Besides, frontline staff usually have better ideas because they live and breathe it every day."

SHOW COMPASSION Dr. Rothfield says he was reminded of an important lesson while recovering from surgical complications: "Never treat the patient as a task or a room number or a disease."

CULTURE OF SAFETY
Compassion Trumps Adverse Outcomes

Some adverse patient outcome are unavoidable. Just ask anesthesiologist Kenneth P. Rothfield, MD, MBA, CPPS, system vice president, chief medical officer and chief quality officer at St. Vincent's Healthcare in Jacksonville, Fla.

Around Thanksgiving 2015, Dr. Rothfield underwent laparoscopic bilateral hernia repair. He went to a surgeon he knew and trusted, and the operation "couldn't have gone any better." He can't say the same of his recovery; he developed sepsis and had to endure an extended hospital stay.

"There was no medical error — just bad luck," he says. "I thought I knew so much, and you find out you don't until you've walked in those shoes. I think it happened to me to give me more authority as a leader, more tools to communicate and more tools around patient safety."

The experience also underscored the importance of treating patients like people.

"In a culture of safety, you never treat the patient as a task or a room number or a disease," he says. "There were a couple of nurses in particular that took great care of me. Their compassion made all the difference."

— Bill Donahue

His advice for tackling any safety-related project: Don't try to recreate the wheel. Use existing toolkits from organizations such as the Agency for Healthcare Research and Quality (AHRQ) and the Institute for Healthcare Improvement, among others, as helpful jumping-off points. Since his organization began promoting a culture of safety, he's been encouraged by the results. For starters, he's seen an increase in reports of near misses by frontline staff, as well as improvements in teamwork, trust and overall safety awareness.

"The culture we should all be trying to build is one of reliability, around the concept of following the same safety protocols with every patient, every time," says Dr. Rothfield. "As good as we think we are, we're not good enough till we have zero patient harm."

Reliability also means the same rules must apply to every individual, regardless of rank or tenure. Say a frontline individual has the courage to voice a safety concern that involves a high-profile surgeon, but leadership responds by saying, "Thanks for letting us know about this, but we need to make an exception this time."

"That's incredibly demoralizing," says Dr. Rothfield.

This is why, every 2 weeks or so, he speaks for an hour to a group of new hires about patient safety. His goal: to let everyone know they have his unflinching support. "At the end of the lecture, I ask them for their undivided attention and say, 'I give you this promise: I'll back each one of you up on any safety concern, even if that concern turns out to be wrong.'"

SMALL BITES Take steps toward a culture of safety by starting with individual "projects," such as reviewing medications to avoid potential dosing errors.

Show your support
Based on the buzz surrounding St. Vincent's patient-safety award, staff seem to be following Dr. Rothfield's lead. The first winner of the award, which includes a financial incentive and a plaque on the wall in the cafeteria, was a CRNA whose courage in "having a difficult conversation" helped to prevent a wrong-site surgery.

Of course, unwanted outcomes can happen even in the most safety-conscious culture. And when they do, it's essential to communicate with patients — staff, too, because an adverse event in which they played a part can be deeply affecting — openly and transparently.

"We have a training course to teach nurses, doctors and administrators how to communicate with patients who have an unexpected outcome, with the goal of repairing relationships," says Dr. Rothfield. "It's a discussion around empathy, where you're telling them you did a thorough investigation and you don't believe it could have been prevented."

And if the adverse outcome was preventable?
"Then the discussion turns to, 'We are so sorry our actions caused this, we are here to support you in practical and financial outcomes, and we're going to help you become whole again,'" he says. "They're expecting us to provide excuses and put up a smokescreen, so they're typically pretty surprised when they hear us use that kind of language. But patients deserve answers, and we don't believe those answers should be delivered in a courtroom." OSM