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Patient Safety Needs a Rescue

Joe Cantlupe, for HealthLeaders Media, May 26, 2011

When I asked Mary Anne Vincent, vice president of performance improvement at St. Joseph Hospital, in Orange, CA, she said those results are disappointing.

"Communication is a barrier in healthcare. So many times I see issues that could have been avoided or minimized with an extra minute or so of 'one-on-one Communications," Vincent says. In many systems, communication is broken down between nurses and physicians by merely the manner in which they  forward their information, she says.

During shift changes, for instance, for some healthcare workers "it's hard to let go of that control," says Shelby Harrington, outcomes specialist for Carolinas Health System, who examined the survey results. But letting go is what needs to be done, she says.


Intelligence Report: The Drive to Patient Safety: Free Download.


An important element in improving communication specifically related to shift changes involves patients themselves, Harrington says. "Giving (patients) a sense of ownership of their own care of what is happening." she said.

"We should be communicating to the patient exactly what we are doing and why we are doing it," Harrington says, "telling that patient, 'I know you've been asked this question, but to ensure your safety, we want to go through your allergy list again.'''

Communication is one thing – between staff and patients. And then there is another level of communication, among hospital staff themselves, and that also appears lacking, the survey shows. Healthleaders are uncertain as to the ultimate responsibility within an organization of who should oversee patient safety initiatives and monitor them.

The survey showed a wide variability of potential leadership for patient safety, ranging from: 25% for executive leadership collectively; 15% for a chief patient safety officer; 14% for a special patient safety committee; 11% for a CEO personally and a designated vice president, and 10% for a chief medical officer.

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1 comments on "Patient Safety Needs a Rescue"


Phyllis Kritek, RN, PhD (5/27/2011 at 9:48 AM)
Since the late 80s we have had a steadily expanding data set that documents patient safety is shaped by our ability as health care providers to collaborate. It has seemed to me that we have elected to use the euphemism of "communication" to avoid the evidence that our failure to collaborate and our tendency to avoid or deny conflict is jeopardizing patient safety. We have elected to tinker with what I call the "low hanging fruit" of patient safety in an effort to skirt the elephant in the room: we sustain our dysfunctional relationships in spite of the evidence that they harm patients. I would observe that recommending that we "stop blaming poor communication and leadership structures and get to work laying out a strategy to secure patient safety" is a continuation of this same avoidance pattern in what has now become a meme in health care. If poor communication and leadership structures are putting our patients at risk, wouldn't the obvious recommendation be that we honestly confront our communication patterns and our problematic leadership structures and FIX THEM? Isn't that the work we need to do and the strategy we have not yet crafted.