It was a Thursday morning three weeks ago, and I had started my morning the way I usually do – I got up, got ready for work, and went into the kitchen to grab my lunch from the refrigerator before leaving the house. As I rounded the corner, I was greeted by small bugs all over my kitchen floor! I immediately grabbed the insect spray and started spraying. The bugs were exterminated, but now the floor was very slick. I knew it was too dangerous to leave it that way, so I grabbed a mop and began cleaning the floor.
With the chore completed, I picked up my keys and briefcase, but I remembered I still had not grabbed my lunch. As I started carefully walking across the kitchen floor, it occurred to me that doing this was probably not a good idea—what if the floor wasn’t completely dry and I slipped, or worse yet, fell? The moment after I had that thought and yet took another step, my left leg slipped forward, my right leg bend backward, and I heard something snap. You guessed it; I broke my leg.
I cannot tell you how many times I have replayed that split second in my mind. Each time I think: “What if I had listened to my gut? I knew better, but I did it anyway!” We all have an internal alarm system that alerts us when a situation feels wrong. I ignored my instincts, and now I am dealing with the consequences.
In many ways, this reminds me of conversations we have had about patient safety and our own efforts at UTMB to create a safer environment for our patients and employees. Our culture of safety demands that we should always speak up and stop what we’re doing if we see or even instinctively feel that something could have the potential to harm a patient.
Last week, the National Patient Safety Foundation released a report entitled, “RCA2: Improving Root Cause Analyses and Actions to Prevent Harm.” The report asks hospitals and health care providers to approach close calls or observed systemic flaws with the same rigor that they do when a major safety event occurs.
The report says that even though the use of the term “culture of safety” is common in health care today, as an industry we have not really made the necessary progress, because creating this culture involves “hard, continuous work and can challenge the status quo.” The report points out that often, safety event reporting systems like our Patient Safety Net (PSN) are used to report what has already happened, not what could have happened, simply based on the system’s design.
As health care providers, we must constantly evaluate the systems in which we are delivering care, and when we are concerned that any system may have flaws, we need to act on those instincts. If we do not, we may be putting our patients at risk.
Once, in a hospital at which I’d worked, a nurse submitted a PSN report to document that the new tubing we had transitioned to for IV delivery was occasionally crimping, thus slowing the delivery of the patient’s medication. Our safety team went to the unit, looked at the new tubing, and realized the nurse was correct. They immediately ordered new tubing, replaced it throughout the hospital, and addressed the problem.
In this instance, the nurse’s instincts were right, and she acted on her instincts. Although we will never know the actual number of patients’ lives that were positively affected by this nurse’s decision to act on her instinct, what we do know is that we were able to correct a system flaw before any patient’s well-being was compromised.
I am certain there are countless stories we could tell of nurses, physicians, residents and other health care staff who have acted on their instincts to keep patients safe. The point is that they acted.
As we go about our important work, let’s be conscious of any system design that may potentially cause harm if we do not identify the flaws and fix them before a patient is affected. Let’s act on our instincts. I certainly wish I had three weeks ago!