You are here: For Providers

Receive this column via RSS feed.

CLINICIAN to CLINICIAN

The power of words: Communication is a critical component of patient safety.

On Jan. 17, the Minnesota Department of Health released its fourth Adverse Health Event report. This annual event is a sobering time for all of us in health care. Every year we read about occurrences that, according to our own professional and personal standards, should never happen.

While documenting 125 adverse health events statewide, it is important to recognize that figure is down from 154 reported last year. Taken as a whole, Allina also improved, reducing our total adverse events from 24 to 15. We can feel good about this progress.

However, as I'm sure you agree, even one adverse event is too many. We still have much to do to ensure that the care we provide is as safe as it can be.

Wrong site/wrong procedure events

One area where we must do more is wrong site-surgeries. In the past year, Allina has had nine wrong site/wrong procedures in our hospitals or outpatient centers. We can do better. This year, our system-wide goal is zero wrong site/wrong procedures in operating rooms.

Communications is a critical component of safety. In one wrong procedure case, a highly respected physician entered the operating room (OR) absolutely certain of the procedure to be performed, while the OR staff was expecting a different procedure to be performed. Before anyone realized that the physician was performing the wrong procedure, irreversible harm was done. Staff deferred to the physician's years of experience and judgment, despite their questions about what was happening. Those questions were not clearly voiced and the physician was unaware of them until it was too late.

In this case, the doctor was certain, but yet was wrong. When the irreversible damage of this error was realized, the patient and family were devastated, as was the surgeon. The missteps of a brief moment in time resulted in tragic consequences that will last a lifetime.

This case demonstrates that no one is immune from error, and it underscores how important it is for staff and clinicians to create and maintain open lines of clear and direct communication. Anyone should be able to call for a stop to double check the procedure or site and, regardless of who does so, it's incumbent on everyone in the operating room to honor the request.

As Dr. Mark Migliori, president of the medical staff at Abbott Northwestern Hospital, recently remarked, wrong site/wrong procedures are "always preventable."

Best practice

Underscoring its commitment to quality, the Allina Board of Directors has asked each Allina hospital and surgery center to demonstrate the best-known practice to eliminate wrong site/wrong procedure events.

Best practice includes:

1. designating a person to be responsible for initiating a pause before surgery
2. coming to hard stop (free of distractions) during the pause to check accuracy
3. completing second stop before a second procedure is performed.

Allina's medical staff leaders have been remarkable in making certain that we are becoming a highly reliable organization in this regard. Leaders are rounding in operating rooms, many sites are asking the proceduralist to do the stop, and teams are holding each other accountable for the safe care of patients by completing these steps each and every time.

I am confident if we recognize that errors can occur and do all in our power to develop systems to continually improve safety, we will achieve our goal of eliminating them from our system.

Everyone on the care team must feel they can speak up if they see something wrong. As one nurse advised, "You have to stop the line and say 'I need clarity!' with an exclamation point."

If we achieve this level of teamwork and communication, patients will be markedly safer and those who provide their care will know they are protecting both the patient and protecting the caregivers whose only goal is to heal.

How can we communicate better?

I welcome your thoughts and observations. Please e-mail me.  

First published: 02/28/2008
Last updated: 02/28/2008

Reviewed by: Penny Ann Wheeler, MD, chief clinical officer, Allina Hospitals & Clinics