The worst part of the best job
Doug Koekkoek, M.D.
Chief medical officer, Oregon Region
June 12, 2013
The least favorite part of any CMO’s job is reviewing sentinel events, safety lapses and malpractice claims. We have some incredibly talented clinicians who work at Providence, and believe me, miracles happen at our hospitals and clinics every day.
But our work isn’t always perfect. Errors happen in health care, and it shakes your confidence when you hear about them – especially if you’re involved.
A review of safety concerns from the first half of 2013 shows some common themes: retained sponges, central-line infections, errors in fetal heart tracing interpretation, wrong-site injections or procedures, and falls with injury.
We have seen fewer of these events over the past few years because we’re catching them before they reach the patient. But new safety efforts, such as the Global Trigger Tool and improvements in our unusual-occurrence reporting, are uncovering more medication-related errors and more adverse events in the perioperative period, such as post-operative aspiration and respiratory failure, positioning-related compartment syndrome, cardiac arrhythmias and so on.
All of this creates a long list of goals for those of us tasked with monitoring safety at Providence.
The path forward is not foreign. It begins with a culture that makes safety a priority, and expects each of us to give our full attention to patient safety. It requires a real commitment to improving teamwork and communication. And it prompts us to follow specific interventions to deliver the safest care, from checklists to hand washing and more, as this chart illustrates.
Keeping patients safe and building a culture around that value requires constant diligence. The only way forward is for clinicians to hold other clinicians accountable. We’ll reassess our culture this fall with another Culture of Safety Survey. When we review those results, my hope is that we’ll have moved the mark – and that the least favorite part of my job becomes less necessary.