For a week last month, we celebrated patient safety. In public corridors, Hospital units and lecture halls, we highlighted our accomplishments, communicated our organizational safety priorities and generated ideas from patients and employees on how better to absorb into our culture the concept of eliminating harm.
During this event, we had booths in the Broadway Corridor and Nelson Lobby showcasing through posters and literature our safety goals, such as improving communication and teamwork among staff, reducing complexity in our systems that can lead to mistakes, and engaging patients and families in our safety projects. We surveyed staff and patients on their awareness of hazards and the potential for medical errors. We even had an academic aspect to the fair, with two grand rounds lectures, and several units presented their patient safety projects. Recognizing that many patient care staff couldn’t break away from their work to attend our fair, we took the activities to them, using a cart to transport the literature, games and demonstrations to units. Dean/CEO Ed Miller took time to work the cart in the neuroscience intensive care unit.
We gave out safety passports that were stamped for each activity in which staff participated. A fully stamped passport made them eligible for prizes donated by the likes of Judy Reitz, who offered tickets to an Orioles game, Pamela Paulk, who offered to take a winner and coworker to lunch at Kali’s Court in Fells Point, and Victor McKusick, who offered a personal tour of the dome. People such as Lori Paine, the Hospital’s patient safety coordinator, put in countless hours preparing and working the week’s activities.
But one event during this week proved to me that we still have a long way to go in making patient safety a seamless part of our everyday operations. On the first day at the McElderry Street entrance to the Outpatient Center, I was handing out buttons that read “Patient Safety Begins With Me.” I was struck by the varied staff responses. House staff almost uniformly hurried past without any awareness of what we were doing. I suppose this reflects their busy workload and their focus on training. Yet communication and safety are now a key part of the competencies on which they, and the institution, will be judged by the ACGME.
A disappointing number of faculty physicians avoided making eye contact as they scurried past, as though patient safety still reminded them that doctors aren’t supposed to make mistakes, and if they do, it leads to blame. Some administrators told me that patient safety wasn’t relevant to them, because they weren’t involved in hands-on care. It was almost as if the words on the buttons were invisible.
Nurses, however, were generally eager to accept a button and took the time to relate patient safety success stories on their units. Quite a few patients stopped to ask if they could have a button, reinforcing the need to include them in our safety programs.
Overall, I found the fair an exhilarating experience and, despite the lack of interest I received from some segments of the workforce, it did, I think, demonstrate the organization’s commitment to safety. I hope that next year, when we hand out buttons again, the reaction will prove a marker on how well we’ve improved our culture of safety.
