By Eric Conn, CEO/President Universal Healthcare Consulting
All my patients are treated safely!
Maybe, but most likely not. Patient safety is always first and foremost for a wide variety of reasons. Obviously the Hippocratic oath states do no harm. And it is abundantly obvious that if a patient is harmed there will most likely be a lawsuit to follow. But let's not forget the elephant in the room and that is that a patient may have been harmed. The point is not to have a practice whereby you never get sued. The goal is to have a practice where patients get treated efficaciously.
Even the most careful practitioners can have a moment where some function was not performed in as complete or careful manner as we would have wished. Sometimes in our haste we may forget to perform all the steps of the protocol. It is at this time something could occur that could result in a bad or even serious outcome. Protocols should be in place so that everyone can follow and document the proper steps to ensure the patient's safety.
We have all been taught that before you put the car into gear you check the mirrors, make sure you have enough gas and put on your seatbelt. We understand that there are certain precautions we should not overlook prior to putting the car into gear and driving off. Before the pilot takes off there is an extensive checklist of systems that all must be gone over and confirmed to ensure the plane is safe to fly you to your destination. In the OR it is the surgeon's ultimate responsibility but not their sole responsibility to ensure that prior to each case, the equipment has been duly checked and is in good working condition. All required and emergency drugs are present, unexpired and in sufficient quantity. A proper time out was called and the procedure, site and patient have been confirmed. But this is not where being disciplined starts and stops. Is the staff following all the prescribed protocols for cleaning the OR between cases and at the end of the day? Are the latest APIC infection control standards being adhered to? Have emergency drills been run though so everyone is aware of their role in the event of an emergency?
I know we all believe we perform our jobs safely. I am sure we feel that everything we do is done in a safe manner and the patients we are performing services on are extremely safe in our care. Besides, you just did a case this morning so why do I have to recheck the crash cart? Follow the entire OR cleaning process? Why do I need to perform the "Time Out" when I just marked the patient in the other room?
Why? Because, everyone involved in patient care has a responsibility to ensure that the patient receives safe treatment. The anesthesiologist should never assume that the next case is a general anesthesia case just before this particular doctor "always" uses general anesthesia. Nor should anything ever be assumed. It should always be asked and confirmed. Protocols should be followed step by step. And cases should never be started unless the OR is 100% compliant and all protocols have also been complied with.
Here are a few examples that could cause a patient tremendous harm but could also be avoided if the compliance protocols were followed:
Eric Conn is President/CEO of Universal Healthcare Consulting, Inc. the leading provider of health care risk management and health care compliance services. Their turn key approach to both office based surgery programs and Ambulatory Surgery (ASC) programs meets and exceeds the standards of AAAASF, AAAHC and Joint Commission, national accrediting body standards. Contact us at 561-999-9371 or email econn@universalhc.com.
