Thoughts on Patient Safety Awareness Week


March 4 to 10 has been “Patient Safety Awareness Week” from the National Patient Safety Foundation.

I'm certainly in favor of patient safety and have worked tirelessly, as have others, to try to improve patient safety from its abysmal starting point (see the statistics here). I tend to roll my eyes a bit at these special weeks, though. Patient safety should be on the front of everyone's minds every day – from healthcare executives to front-line staff. The fact that we have a special week is probably a sign of the dreadful current state of patient safety.

I don't think the airlines have “Passenger Safety Awareness Week.” While the airlines aren't perfect, air travel has gotten much safer over the past few decades, while healthcare has not.

What did your leaders or health system do this week to raise awareness of patient safety? Better yet, what was done to improve patient safety in a meaningful way?

Sadly, many programs for improving patient safety seem to blame the front-line staff, as if it's their lack of education or lack of awareness that causes the problem. Quality and patient safety are SYSTEMS issues. As Dr. Deming said — who designs the system and is responsible for it? Senior leadership. Leaders need to look in the mirror at their organization's culture and leadership styles. What encourages teamwork, process improvement, and quality/safety and what gets in the way?

Stories of quality and patient safety improvement usually seem to be stories of management systems, not technology or simple tools. Virginia Mason has changed their culture and management systems with their “patient safety alert” system. This system isn't a specific technology, but rather a change in the culture that makes it OK for people to raise their hand to highlight problems or concerns. ThedaCare is an example of a system where leaders, from the CEO on down, have changed their behaviors to help improve the culture of safety and quality.

I don't think any number of cute posters or buttons for staff to wear are going to solve the patient safety crisis (yes, it's a crisis).

I've been a critic of programs that ask patients to speak up about hand hygiene. That puts an undue burden on the customer (the patient) to ensure quality, when that should be the job of hospital leadership. I don't think asking patients to speak up is a meaningful way to improve quality (especially because patients are often afraid to speak up for fear of reprisal).

See this post from a nursing website: “I'm supposed to wear an “Ask me if I washed my hands!” button?!“. The nurse is right that efforts like these are insulting, especially when the doctors aren't required to wear these buttons (and data suggests nurses are generally better than doctors about following hand hygiene practices). As the nurse wrote:

I find this incredibly insulting both to my intelligence and to my professional practice as an RN. I cannot imagine what patients must be thinking: does it imply that we don't know enough to wash our hands? What else do they need to be checking up on, if we can't be trusted to have washed our hands after patient contact?

I understand that the aim is to decrease the spread of microorganisms. We all learned that in Nursing Fundamentals. I've listened to all the inservices on handwashing, antimicrobial foam and gel, and standard precautions ad nauseum. But this is way over the top. I don't ask my mechanic if he remembered to put all the parts back in my car and I don't ask my accountant if she used a calculator to figure out my taxes. I don't think I should be asked over and over if I'm doing my job, either.

I've often used that same analogy about the mechanic. When you get your tires changed or rotated, does the mechanic have a big button that says “ask me if I tightened the lug nuts?” I created this image for my talk at the upcoming Lean Healthcare PowerDay event where I'm speaking:

Does the humble tire shop put this burden on the customers? No. They have trained staff (as do hospitals), but the mechanics also have systems (including checklists) and they also (hopefully) have the time available to do the job properly without having to rush or cut corners. A wheel falling off a car (due to loose lug nuts) can be deadly, by the way.

In hospitals, there are many practices that SHOULD happen. They staff know about the practices, it's not a lack of awareness. Staff should follow proper hand hygiene practices, they should do pre-surgical time outs and checklists, they should do hourly rounding to help prevent falls, they should reposition patients every two hours to prevent pressure ulcers… but these things don't happen consistently.


The response often comes back: “We don't have time” (often accompanied by a shoulder shrug).

There's the systemic issue — not having enough time. We could try to blame the staff for not managing their time well, but we can also look at the system. Why is there too much waste in the system (such as wasted motion or time wasted on slow/clunky computer systems)? Why aren't we addressing those problems to free up time so we can do things the right way?

Does Toyota allow half-built cars to roll off the line because they “didn't have time” to put the doors on? Of course not. They have designed and managed their system for quality. Yes, hospitals are more complex — all the more reason to give MORE attention to the design and management of the system.

If the two-hour repositioning isn't happening, more patients will get HAPUs (hospital-acquired pressure ulcers). This harms patients and can cost a hospital MILLIONS of dollars (since that's not reimbursed as a preventable “never event”).  Do front-line managers (or the COO and CEO) know what percentage of the time high-risk patients are being repositioned? Is it 100%? Less? If less than 100%, why?

If hospitals were serious about fixing the problem, they wouldn't let “we don't have time” be an excuse. It might not be the most creative approach, but why not throw people at the problem, especially if the cost of additional staff is less than what you lose through unreimbursed care? Then, go fix the waste in the system so you don't need as many people.

Either way, we need fewer posters, less popcorn, and more improvement. What can you do to make National Patient Safety Awareness Week into an improvement week? And next week?

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. A barrier to quality – my friend Dan Markovitz tells a story in this webinar (about 19 minutes in):

    Where nurses in a TX health system spent 6.2 hours a shift (a bit over half their time) on paperwork. They were able to cut that time in half, freeing up more time for patient care (therefore, quality and safety).

  2. I agree time should never be an excuse to cut corners. Mistake proofing is a vital component in regaining precious time. If you can’t do it incorrectly then you only need to check that it was done. In other words design quality into the system. What I would suggest however is that each job title has one person that spends 30% minimum of their time leading process improvements. The people performing the the jobs are the best experts.

    • Agreed, David, that the people doing the work are the experts. Hospitals don’t dedicate nearly enough time to process improvement, whether it’s time for staff or “process engineers.” Even non-Lean manufacturing companies have dedicated engineers and staff, which isn’t as good as the Lean model of having front-line staff involved in process improvement.

      Hospitals, sadly, are more likely to send nurses home early because the patient census is low. They need to start using some of that time to allow them to work on quality and efficiency improvements.

  3. Mark,

    As a an ICU staff nurse patient safety is my first priority. And if you spoke to my colleagues they would say the same. The frustration we face is a combination of non-essential responsibilities that consume time, unrealistic expectations, inefficient work processes, and dangerous working conditions. It’s a recipe for problems. Lower nurse:patient ratios would help a great deal. Nursing is a labor and intellectually intensive process that can not be substituted with technology. It requires nurses to have their hands on (and sometimes in) the patient, to continually administer the treatments and assess the response to them.

    From what I can see, administration’s success lies in the success of the processes that they implement. Ergo it is imperative that the process succeeds because it is a reflection of the administration and so the process failure must be a result of staff (usually nurses) failing to implement it properly. Admitting that the process may be faulty would suggest that administration might be faulty and bear responsibility in the poor safety records. No where have I heard in the media that the administration and their processes are responsible for the problems. Rather, what I do hear is that the nurse didn’t do step “X” in a process, created by people who have no idea how care delivery plays out on a unit, and that’s why a patient was injured. You promote the idea that the processes are the problem. Unfortunately, what I see is that administration practices protecting the process and blaming the staff for not following them properly.

    • Susan – first off, thank you for your important and special work as an ICU nurse.

      You are absolutely right that the media never focuses on the role of leaders and senior leadership in quality. In cases like the Quaid twins’ overdose, the CMO at Cedars-Sinai was blaming staff for not following procedures… taking no responsibility for the question “why weren’t staff following procedures?” or “why were the procedures faulty?” since multiple nurses gave those kids the wrong med.

      Paul O’Neill, former CEO of Alcoa and a ringleader of the Pittsburgh Regional Health Initiative, is one of the few who says the problem with safety and quality is LACK OF LEADERSHIP. has a podcast of him talking about this. He sometimes gets a broader media spotlight (like CNBC) to talk about these problems.

      The problem is not the nurses. If there’s understaffing, that’s not the nurses’ fault. All the things you describe in the first paragraph of your comment are not the nurses’ fault – that’s management’s responsibility.

      I get tired of hearing about healthcare professionals get thrown under the bus (or thrown in jail) while healthcare leaders are hardly ever responsible or held accountable for what happens in their organizations… leaders need to quit blaming staff. They need to take responsibility. Processes are the problem – management and senior leaders ultimately own those processes.



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