The most powerful voice in the room

Doug Koekkoek, M.D.
Chief medical officer, Oregon
Chief executive, Clinical Services and Providence Medical Group

July 16, 2014

In the last issue of Pulse, Dr. Steve Freer explained how our thinking patterns, the mental shortcuts that help us make complex clinical decisions quickly, can betray us in unexpected ways.

This is especially evident with medical errors and complications. Wrong-site injections, retained sponges or medication mistakes often are the result of absentmindedness – rote thinking habits gone astray. Couple that with a lack of communication, the most common root cause of preventable error, and you have a sentinel event waiting to happen.

Providence's quality teams work tirelessly to build systems that will prevent errors, but no protocol or checklist can replace the most important factor in keeping our patients safe: ourselves.

When we're busy and distracted, do we remember to pause, become fully present and focus on the task at hand? Do we double-check our work? Just as important, do we speak up when we see a safety risk? Do we empower others to do the same?

Combined, these contribute to a culture in which safety is paramount.

Providence Health & Services recently updated our Root Cause Analysis Toolkit, a guide for examining the causes of sentinel and adverse events. Beyond looking at the steps that lead to adverse events, we're also examining broader cultural influences – our system designs, management expectations and accountability, and employee empowerment.

Providence hospitals have made strides in creating a strong culture of safety, and our high scores for patient safety are proof of that. Protocols and outcomes, however, are just two measures of high performance, and perhaps not even the most important. After all, we can make honest mistakes or, in rare cases, engage in risky practices with no negative consequences – that time.

A truer test of a healthy culture of safety may be our own behaviors and attitudes. We're all responsible for safety, regardless of our role or function. If we see a better way to do things, or a behavior that may lead to unnecessary risk, we owe it to our patients to speak up. A safety culture is a learning culture. This is how we prevent errors from happening and how we "do the right thing, right."