This Is Patient Safety Awareness Week
The adage "first, do no harm" is usually attributed to Hippocrates. While we as individuals live by this adage, there is good data from the World Health Organization to show that mistakes that cause harm are mostly due to system or process failures. This knowledge underlies our goal of being a high reliability organization. As a part of this goal, we work together to improve our systems and processes, recognizing the impact that they have on individual people.
I carry with me a case from residency that I think of almost 30 (!) years later. A patient presented to the Emergency Department (ED) unconscious with a presumed brainstem stroke in progress. He hadn't responded to Narcan and his exam was worsening. The resident saw in the computer that his glucose and other labs were normal and we rushed the patient to the scanner. Surprisingly, all of his CTs were negative. He continued to worsen – his pupils became non-reactive and he was intubated. The team worked together frantically as he became progressively less stable. He was dying in front of us.
In training, we learn to reassess and, in this case, to try to make sense of what is happening. The resident went back to the computer to review the labs and see if anything new had come back. When he refreshed the page, the answer was clear and I still remember the look on his face. The patient's glucose was 18 – critically low. The way the lab screen was set up made it hard to tell that the resident had initially seen the normal labs from an admission on the same day exactly a year prior. Because the glucose was thought to be normal, no one noticed that the protocol to check a chemstick hadn't been followed. To add to that, there wasn't a notification phone call to the ED that the lab was critical.
In the ensuing decades, we've learned to build our systems and processes with all of these potential points of failure in mind. Our lab displays are clearer, our double checks are more robust, our critical notification systems are more ingrained. We take these events and these near misses as an opportunity to do better. They inform our approach to patient care and to patient safety.
We all have a role to play in advancing safe health care for our patients, and while we do this incredibly well here, core to our culture is that commitment to continue to get better. We do this for our patients from 30 years ago, for today's patients and for those we will care for in the future. Thank you for your unwavering commitment to absolutely safe practices here at EvergreenHealth. I'm proud of the work we do together.
