Sexy Astronaut

Many Americans might consider 2008 a year less than stellar. Outside of the region's economy and geopolitical events is, we can not ignore the alarming fact that our health system fails to keep patients safe. The Joint Commission reports that 815 individual sentinel events occurred in 2008, with approximately 70% of deaths resulting from the patient. Each of these events is unique, with its own set of circumstances, his own clinical setting, and his own doctors. Every tragedy has its own victims, including families, relatives, and "secondary victims", the clinicians involved. In addition, millions of dollars were paid by the hospitals of these errors; dollars which could be devoted to prevention of errors.

Only the most bitter cynic might say that these unfortunate results have been intentional. In fairness to health care teams involved, each member, if asked, would probably say they did everything possible to "do the right thing" to achieve the desired outcome for the patient. This state mind, although necessary to achieve high quality care is insufficient to provide health care safe.

In other words, the purpose of conducting an analysis of the sentinel event root cause next is to find the answers to what is often very difficult questions: "How could this happen? What is wrong with our training? Who is to blame? "Even in all, it is difficult to identify a general" Universal Root Cause "simply because every case is different. The best way to find that "Holy Grail" of patient safety can begin by focusing less on what happened during these events, and what did not happen.

A successful parenting technique I used to address the adverse effects of low grades, curfews bumps in the family car, and failed, targeted prevention issues involved punitive. Rather, I asked my questions, as analytical tools, ie "Have you done everything you avoid this?" This allowed me to get a different perspective and better results.

Imagine using the same technique in question, coupled with a tone of compassion and non-judgmental, and asks each of the clinicians involved in the 815 tragedies that have occurred this year, "Have you done everything you to prevent this? "

Their answer thoughtfully and honestly would be too often: "No, in retrospect, I have not."

It's more than just semantics. There is a subtle difference between the cultures "always do the right things" and those who actively do what they need to keep things "bad". This culture is a culture of safety, especially under a "first, do no harm".

What are the best practices for safety culture?

# 1 - ask others to check your work

This behavior, although incredibly simple, is surprisingly difficult for some to adopt. Assuming that you are human and therefore fallible is the first step toward asking others to check your work. Captain Robert "Hoot" Gibson, an astronaut with five space shuttle flights under his belt, often invoked "Lois Hoot" has during his tenure as head of the astronaut office. These "laws" were a set best practices that he had realized for many years in high-risk companies. One of the immutable laws to ensure success in a hostile environment, such as health or space flight, is "If it is essential to the success missions, and two pairs of eyes should be on him. "Even when working with the best and brightest, there was an open admission that mistakes could be made.

In health, it is not always clear when to seek a second opinion. Do not expect all clinicians to know how to do it effectively.