By Paul Levy

First Posted at Not Running a Hospital on 10/20/2012

Paul Levy, Host of (Not) Running a Hospital
Gina Pugliese, vice president, Premier’s Safety Institute

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.”

Patricia Salber MD, MBA (@docweighsin)
Patricia Salber, MD, MBA is the Founder and Editor-in-Chief of The Doctor Weighs In. She is also the CEO of Health Tech Hatch, the sister site of TDWI that helps innovators tell their stories to the world. She is also a physician executive who has worked in all aspects of healthcare including practicing emergency physician, health plan executive, consultant to employers, CMS, and other organizations. She is a Board Certified Internist and Emergency Physician who loves to write about just about anything that has to do with healthcare.


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