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Instant Gratification

By Jock Hoffman, CRICO

Related to: Clinical Guidelines, Emergency Medicine, Primary Care, Nursing, Obstetrics, Other Specialties, Surgery

In February 1825, Samuel Morse was working as a portrait painter in Washington, DC. When his wife, at home in Connecticut, fell gravely ill, Morse received notice via a horse messenger. He rushed home, but was too late: he had missed her final days, her funeral, and her burial. In his grief, Morse devoted himself to accelerating the speed of urgent communication and, ultimately, invented the telegraph (and the Morse code). We have not slowed down since. Today, even though the U.S. Postal Service can deliver a letter from coast-to-coast in 24 hours, people refer to it as “snail” mail. Last August, when an earthquake shook central Virginia, people in New York City received Twitter tweets about it before they felt the associated vibrations. Remarkably, even instant notification of important news is no longer considered to be “fast.”

In recent years, patient safety activities have likewise been accelerated. Not too long ago, it was standard procedure to base patient safety recommendations entirely on data from a small set of malpractice cases triggered by health care encounters up to 10 years prior. And those data were held close the vest and shared only with those with a need to know.

But today, under the protections of the federal Patient Safety Organization (PSO) program, a health care organization—or even just a clinical department—has the opportunity to share and discuss very recent adverse events or near misses (i.e., immediate concerns) with local and national peers. More important, PSO participants might be able to walk away from those same meetings with their peers’ recommendations for addressing the still-present risks identified in those contemporaneous events. The time line from occurrence to remedy has been truncated from years to weeks. The potential benefit to physicians and their patients of an accelerated process is self-evident.

At the same time as we shift into a higher gear for identifying risks and remedies, patient safety professionals are also adjusting how they promote an optimal safety culture within high-risk settings. Individual clinicians experience malpractice claims—and even adverse events—as extremely rare occurrences amidst an overwhelming majority of care that is appropriate and safe. Any effort to draw attention to the opportunity to improve patient safety is—at the individual level at least—competing with myriad clinical, financial, and quality of life pressures. Physicians and nurses want to be safe, of course, but the prioritization for broad safety initiatives is more likely to be driven at the practice group, department, or organization level. Participation in a PSO enables clinicians and risk managers to pair the tragedy and dismay of a big picture malpractice legacy with the intimate local concerns triggered by last week’s near miss.

As CRICO and other organizations driving the patient safety improvement movement work with those groups, departments, organizations, and interinstitutional teams, this real-time problem solving is more likely to rivet their attention than the traditional model. That, in turn, is key to devising appropriately targeted patient safety improvements and trainings that have a high likelihood of being adopted and sustained…faster than ever before.

November 1, 2011
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