Throughout 2019, Becker's asked numerous clinical leaders the following question: "If you could fix one patient safety issue overnight, what would it be and why?"
Their responses are below.
Editor's note: Responses were lightly edited for clarity and length.
Anne Marie Benedicto, MPH
Vice president of the Joint Commission Center for Transforming Healthcare
Intimidating behaviors. The layers of intimidation in healthcare organizations can lead to errors, because people are so scared to speak up, ask questions or share ideas. This creates an unsafe environment because people who are not going to speak up will also hold their tongues when patients are involved. If you can't talk about the bad things, you can't talk about the good things either. The healthcare organization misses out on identifying the unsafe conditions to prevent harm and also on the good ideas employees have to improve their organizations.
Jeffrey Boord, MD
Chief quality and safety officer at Fort Wayne, Ind.-based Parkview Health
If I could change one thing, it would be optimizing teamwork and communication. Far too many patients are harmed by medical errors in the U.S., and the root causes of those errors involve breakdowns in teamwork and communication. Providing healthcare is a very complex task with many risks. We also need to have better systems to deliver care, but effective teamwork and communication is really essential to optimize safety and outcomes both for workers and patients.
Lakshmi Halasyamani, MD
Chief quality and transformation officer at Evanston, Ill.-based NorthShore University HealthSystem
I would want to fix the distractions that make providers be less present in the moment. Oftentimes, we're not fully taking in all the information we have in front of us. We're not integrating it in a way that gives us the best decisions. Sometimes that is because we get interrupted. Sometimes it's because we are distracted by something else. Providers need to have clarity of thought in those moments so they can fully understand the information in front of them, whether that is presented by another provider, in the patient record or directly from the patient.
In addition to having that presence of mind, I would also want people to feel like it is safe for them to speak up or raise any questions or concerns they may have in an environment that is really focused on trying to get to the best decision. To me, it's a blend of both having the presence to understand the information, but also as you're synthesizing it, being able to very openly speak up about potential concerns. Those two things together are the most important safety issues to fix.
William Isenberg, MD, PhD
Vice president of patient safety at Sacramento, Calif.-based Sutter Health
If I could fix one thing by snapping my fingers, it would be fixing how promptly clinicians reach the right diagnosis and institute therapy. For example, I'm an OB-GYN by training. A woman could come to me saying she's interested in birth control. I may know that the last 50 women who started on a certain pill had good bleeding profiles, but I could still pick the wrong pill for this patient. But what if I had the data capabilities to look back at the last thousand women started on this specific birth control pill who have the same medical characteristics as my current patient? Then I could ensure the patient receives the right pill from the get-go and prevent her from having to come back and see me a month later. We have 3 million patient records on one EHR at Sutter Health and a whole research institute that's working on diving into the data for insights like this.
Stephanie Jackson, MD
Senior vice president and chief quality and clinical value officer at Scottsdale, Ariz.-based HonorHealth.
There are so many. If I had to pick one, it would be medication reconciliation. It's been a problem my whole career. Nationwide, about one-third of patient harm is related to medication. It's a difficult nut to crack because there are so many different caregivers involved in the process across the care continuum. There's also been a proliferation of new drugs, and providers are not as familiar with all the medications. It's hard for them to keep up, especially when patients are on a lot of medications.
Jonathan Perlin, MD, PhD
CMO and president of clinical services at Nashville, Tenn.-based HCA Healthcare
This takes me back to the roots of quality. If I could improve one thing around the country and world, it would be hand hygiene. Sometimes it's not about the big gains, but the little things that every caregiver and family member does that can affect patients. It's often said that if healthcare could be as vigilant about hand hygiene as cruise ships, we'd save many lives.
Michele Saysana, MD
Vice president of quality, safety and performance improvement at Indianapolis-based Indiana University Health
What keeps me up at night and gets me out of bed in the morning is the goal of better understanding quality and safety opportunities across the care continuum. If I could fix one thing, it would be to know exactly what's going on in all of our outpatient sites and how we could better help and support those teams. That's really where our patients get the majority of their care — in our primary care offices, emergency departments, infusion centers, etc. We have to get better about focusing on the true continuum of care, rather than just what's going on in our hospitals.
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