Saturday, October 20, 2012

View near misses as a gift

Gina Pugliese, @gpugliese, vice president of Premier's Safety Institute, offers thoughtful advice to improve the collaboration and quality of care in operating rooms on Becker's Clinical Quality and Infection Control .  Here is the one I like best, unfortunately a rule more often broken than observed.

View "near misses" as a gift. Ms. Pugliese says hospitals need to eliminate the "culture of blame" that pervades our society. When something goes wrong, she says the natural tendency is to look for a culprit: Whose fault was it? Who didn't do what they were supposed to do? She says while an individual may be responsible for a mistake, usually it can be tied to a "systems breakdown," where the lack of a checklist or a system of checks and balances allows tasks to fall through the cracks.

She says hospitals should instead step back and view "near misses" — situations where something almost went wrong, but didn't — as a gift. It gives the OR team a chance to assess what happened during the surgery and determine what went wrong to allow the near-miss to occur. She says it's important to include front-line workers in these discussions, because often they can identify systemic problems that frequently cause issues with patient safety. "Maybe the staff doesn't have enough IV pumps that have programmable ways to prevent medication errors, so they have to use the other ones," she says. "You want to know what keeps staff up at night, what bothers them."


Jimmy Dong said...

Hi Paul,

I've been following your blog for a couple months now and I think there are some great things you help to bring attention to on here. I was hoping that you'd be able to share some insight with me on how to best approach healthcare as a career.
I'm currently a senior at Columbia University studying Operations Research, and I'm a bit torn between applying to a PhD program to study healthcare operations vs some combination of MPH, MHA, and MBA. I've taken a few classes on studying healthcare operations as well as quality of service and resource allocation, and I think that health is a field of critical importance that I'd like to work in. But, there seems to be little information about how to go about entering the field of healthcare operations. If you have any thoughts or could point me to some resources, I'd greatly appreciate it.


Paul Levy said...

Jimmy, please send your email.

Paul Levy said...

Meanwhile, in case this helps:

Michael Wong said...

Near misses truly are a patient safety gift. Read Matt Whitman's near miss. He writes, "by the grace of God, an observant nurse who just happened to walk by my room when I stopped breathing, called a “Code Blue”, and that ultimately saved my life". For his article, please see: