There is a disturbing story coming out of Tennessee that every healthcare professional and hospital administrator should pay attention to. According to reports, several patients undergoing orthopedic procedures at a Nashville hospital were harmed in a medication-related event. The family of one of the patients alleged that potassium chloride was administered into a spinal instead of the intended anesthetic, leaving the patient paralyzed. The investigation is ongoing, and I certainly don’t know all the facts.

So this isn’t about blaming an individual physician, nurse, pharmacist, or hospital. It’s really about something much bigger that I want to discuss, and that is why quality and patient safety matters.

You see, after many years serving in healthcare leadership roles in quality and patient safety, I’ve come to believe that many serious safety failures ultimately involve two fundamental principles, which I refer to as ownership and communication.

Ownership

Ownership means that every person along the chain of care takes responsibility for the task entrusted to them.

So when a medication is prepared, labeled, transported, handed off, checked, and ultimately administered, every step matters. Every person in that chain has to own their piece of it.

Healthcare is complicated. We’re busy. We get interrupted. But when someone’s life literally is in our hands, we have to focus on the task in front of us, the task at hand.

Think about how an airline pilot prepares for takeoff. That pilot may have flown thousands of times, but the checklist still gets done.

Why?

Because familiarity can never replace discipline when lives are at stake.

Communication

The second principle is communication.

Medicine has learned enormously from aviation, a concept known as crew resource management. You see, in the cockpit, everyone has a responsibility to communicate clearly. If something doesn’t look right, someone needs to speak up. Information is repeated and confirmed. Ranks should never prevent a team member from raising a safety concern.

Healthcare must operate the same way.

A nurse should feel comfortable questioning a surgeon. A pharmacist should be comfortable stopping a process. A technician should be able to say, “You know, something just isn’t right here.”

And the person receiving that concern has an obligation to listen.

People sometimes say, “Human error is inevitable.” You know, I get that. We’re all human. But I never have been comfortable accepting that statement as the endpoint of a patient safety discussion.

Building Systems That Protect Patients

Our responsibility is to build systems that anticipate human error and prevent it from reaching the patient.

Such things as barcoding, standardized labeling, independent verification, medication segregation, checklists, readbacks, timeouts, closed-loop communications.

These aren’t bureaucracy.

They’re barriers between a mistake and a patient.

In quality, we often talk about never events. Those are catastrophic occurrences that should simply never happen.

A Culture of Accountability

The goal isn’t to create a culture of blame. It’s to create a culture of accountability, a culture where everyone takes ownership, a culture where everyone communicates, and a culture where anyone, regardless of title, can stop the line when something doesn’t seem right.

Because behind every medication, behind every procedure, every checklist, every handoff is something we can never afford to forget.

There is a patient trusting us with their life.

And protecting that trust is the most important responsibility we have.

I’m Dr. Raymond Singer. I hope this was helpful. Stay safe and I’ll see you next time.

ᴅɪꜱᴄʟᴀɪᴍᴇʀ: ᴛʜɪꜱ ᴠɪᴅᴇᴏ ᴅɪꜱᴄᴜꜱꜱᴇꜱ ᴘᴜʙʟɪᴄʟʏ ʀᴇᴘᴏʀᴛᴇᴅ ᴀʟʟᴇɢᴀᴛɪᴏɴꜱ ᴀɴᴅ ɪꜱ ɪɴᴛᴇɴᴅᴇᴅ ꜱᴏʟᴇʟʏ ꜰᴏʀ ɢᴇɴᴇʀᴀʟ ᴇᴅᴜᴄᴀᴛɪᴏɴ ᴀɴᴅ ᴅɪꜱᴄᴜꜱꜱɪᴏɴ ᴏꜰ ʜᴇᴀʟᴛʜᴄᴀʀᴇ Qᴜᴀʟɪᴛʏ ᴀɴᴅ ᴘᴀᴛɪᴇɴᴛ ꜱᴀꜰᴇᴛʏ. ɪ ʜᴀᴠᴇ ɴᴏ ꜰɪʀꜱᴛʜᴀɴᴅ ᴋɴᴏᴡʟᴇᴅɢᴇ ᴏꜰ ᴛʜᴇ ɪɴᴄɪᴅᴇɴᴛ, ᴀɴᴅ ɴᴏ ᴄᴏɴᴄʟᴜꜱɪᴏɴꜱ ꜱʜᴏᴜʟᴅ ʙᴇ ᴅʀᴀᴡɴ ʀᴇɢᴀʀᴅɪɴɢ ᴛʜᴇ ᴀᴄᴛɪᴏɴꜱ ᴏʀ ʀᴇꜱᴘᴏɴꜱɪʙɪʟɪᴛʏ ᴏꜰ ᴀɴʏ ɪɴᴅɪᴠɪᴅᴜᴀʟ ᴏʀ ᴏʀɢᴀɴɪᴢᴀᴛɪᴏɴ ᴡʜɪʟᴇ ᴛʜᴇ ᴍᴀᴛᴛᴇʀ ʀᴇᴍᴀɪɴꜱ ᴜɴᴅᴇʀ ɪɴᴠᴇꜱᴛɪɢᴀᴛɪᴏɴ. ᴛʜᴇ ᴠɪᴇᴡꜱ ᴇxᴘʀᴇꜱꜱᴇᴅ ᴀʀᴇ ᴍʏ ᴏᴡɴ ᴀɴᴅ ᴅᴏ ɴᴏᴛ ʀᴇᴘʀᴇꜱᴇɴᴛ ᴍʏ ᴇᴍᴘʟᴏʏᴇʀ ᴏʀ ᴀɴʏ ᴀꜰꜰɪʟɪᴀᴛᴇᴅ ᴏʀɢᴀɴɪᴢᴀᴛɪᴏɴ.

Interested in my book? You can buy it on Amazon!

(𝘛𝘩𝘦 𝘷𝘪𝘦𝘸𝘴 𝘦𝘹𝘱𝘳𝘦𝘴𝘴𝘦𝘥 𝘪𝘯 𝘮𝘺 𝘱𝘰𝘴𝘵𝘴 𝘢𝘳𝘦 𝘮𝘺 𝘰𝘸𝘯 𝘢𝘯𝘥 𝘥𝘰 𝘯𝘰𝘵 𝘳𝘦𝘱𝘳𝘦𝘴𝘦𝘯𝘵 𝘵𝘩𝘦 𝘷𝘪𝘦𝘸𝘴 𝘰𝘧 𝘮𝘺 𝘦𝘮𝘱𝘭𝘰𝘺𝘦𝘳 𝘰𝘳 𝘢𝘯𝘺 𝘰𝘳𝘨𝘢𝘯𝘪𝘻𝘢𝘵𝘪𝘰𝘯.)