The Shocking Truth About Patient Safety and Risk Management

An average of 200,000 Americans die in hospitals annually from medical mistakes. That is the equivalent of 390 jumbo jets full of people. Four years ago today, a lack of basic Patient Safety measures had a catastrophic consequence: It cost my Dad his life. Had a culture of Patient Safety been prevalent in the operating room, I wouldn’t be writing this post. Patient Safety and Risk Management is something that we all should be concerned with. When there is a lapse in Patient Safety, it steals our spouses, parents, grandparents and friends.

My Dad was a former United States Marine Corps Aviator and a Delta pilot for 36 years. Safety was ALWAYS his number one concern. The safety of his crew and the safety of his passengers were not a responsibility he took lightly. As a child I would ask him when things got bad in the airplane, be it weather or mechanical issues, if he ever worried about getting his passengers home safely. His reply was always simple: “As long as we know our procedures cold, continue to fly the airplane and talk to each other, the two of us upfront will be OK- and that means everyone onboard will be OK too… And they love their families as much as I do.

Today’s military and commercial aviation communities use processes that keep them 99.9996% accident free. These processes cover skill sets for teamwork, clear communication, discipline, collaboration, standard protocols, self-incident reporting procedures, and decision making. In the aviation industry, the concept of “Crew Resource Management” empowers anyone on the flight deck to challenge another pilot if they see a potentially fatal blunder in the making.

But there is a fragile culture in the operating room. Egos can get in the way, and surgeons are often treated with complete deference because of their sophisticated skill sets, and as a result there is hesitancy for nurses and other staff to speak up – even if THEY see a problem. Understandably, the atmosphere in an operating room can be tense. But patient safety is at risk.

However, poor communication between hospital support staff nurses and surgeons is the leading cause of avoidable surgical errors. Improving communication, collaboration, and teamwork between physicians, nurses, staff and patients is critical.

Straight forward techniques that are used routinely in the cockpit: pre-flight briefing’s (pre-operative briefing’s), checklist’s, the ability to call a “time-out’ or a ‘knock-it off’ when there is a concern, and routine Debrief’s, could all reduce the error rates.

Health care is becoming ever more sophisticated. With continual advances in technology and equipment, surgeons and physicians can’t know everything. It takes a team to be successful.

But Patient Safety needn’t be a victim. Nor should your family member.

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