Patient Safety Awareness Week 2016: Still Much Work to be Done


Screen Shot 2016-03-12 at 6.43.40 AMThis week is the annual Patient Safety Awareness Week. As the National Patient Safety Foundation says, “Every day is patient safety day.” I've expressed similar sentiments here on the blog before. I think we need more ongoing efforts to raise awareness, for healthcare professionals and the general public, about the scale of the problem AND the proven methods that can improve patient safety.

I'm an advocate for Lean healthcare, but I'd like to think I'm first a foremost an advocate for patients and for patient safety… and that I'm an advocate for the hardworking, caring healthcare professionals who are caught up in bad processes and dysfunctional cultures. Lean is  means to an end… and the most important end is eliminating preventable medical harm.

See my collected statistics about patient safety and harm (it's a global problem) and some statistics about cases where safety has been improved. We need to collect more of those improvement stories and examples.

It frustrates me when I hear about healthcare organizations that have somehow gotten the notion that Lean is only about cost and efficiency. “Safety first” is more than an empty slogan in a truly Lean organization and Lean certainly provides methods and mindsets that help improve quality and safety… but it requires leadership. As Paul O'Neill told me a few years ago, the bottleneck is leadership, or the lack thereof.

And, it's not just an American problem. See this story that a friend from England sent me recently: “NHS ‘never events' a disgrace, says Patients Association.”

“The so-called never events included the case of a man who had a whole testicle removed rather than just a cyst.

In another, a woman's fallopian tubes were taken out instead of her appendix.”

These “never events” happen far more often than never. “So-called never” is the right phrase and it's one I've used before.

The Louise H. Batz Patient Safety Foundation

Screen Shot 2016-03-12 at 10.33.52 AMI'd encourage you to check out the Louise H. Batz Patient Safety Foundation, a Texas-based non-profit… I serve on their board. They have a recently redesigned website and a number of FREE resources for patients and families, including the “Batz Guide “book and (free) iPad app that can be used to help better manage your care and prevent problems (it's a shame we put this burden on patients, but it's necessary in this day and age).

If you work for a health system, the Batz Foundation can work with you to bring Batz Guides in, making sure nurses and staff know about the Guides and how they can be best used for everybody's benefit.

The Foundation is also holding a special contest this week:

Patient safety is no one person's responsibility and we encourage you to submit your own patient safety story. Let us know about a great catch, a co-worker who has gone out of his or her way to care for someone entering the hospital, or just share a great patient safety tip. Everyone who submits a story will automatically be entered into a drawing to win an iPad mini and free download of our new app.

I'm also happy to support the Foundation, as proceeds from my Practicing Lean eBook project ($500 so far) go to the Foundation.

AHRQ – Progress & Resources

I'm adding this to the post after receiving an email from AHRQ:

“AHRQ is United for Patient Safety. Let's keep the momentum going. Hospital-acquired conditions declined 17 percent from 2010 to 2014 saving 87,000 lives and nearly $20 billion in unnecessary costs. Everyone in the health care process plays a role in delivering safe care. AHRQ has created tools to help your facility reduce readmissions, hospital-acquired conditions–including infections–and improve health literacy, patient/family engagement, and boost quality performance. All of our tools are evidence-based and available at no charge. Check them out.

Follow them on Twitter @AHRQNews for daily updates. Join AHRQ and other organizations for a Twitter chat “Safety in All Settings” on March 15 at 2 p.m. ET. Use #PSAW16chat. Also, don't miss the free webinar “Patient Safety is a Public Health Issue” on March 17 at 1 p.m. ET.. Register here.”

Patient Safety Week Podcasts

Later this week, I have two podcasts talking about healthcare quality and safety improvement:

What Are You Doing and Seeing?

If you're working at a healthcare organization, what is your organization doing to promote or celebrate Patient Safety Awareness Week? Talking about the problem doesn't make it worse. I hope most organizations are at the point where they can speak open and honestly to their patients and communities about the need for patient safety improvement.

What is your organization doing to improve patient safety? Is Lean, hopefully, part of that equation? If not, why isn't Lean part of the safety and quality efforts?

As a patient or as somebody outside of healthcare, what can you do this week to help raise awareness about this important issue?

Personal Stories

Here are a few other podcasts on the subject, with some very gripping personal stories:

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And I'll again post this video from last year that really touched me:

Let's roar… let's be brave and strong and improve patient safety. To our healthcare leaders… you need to set the tone and help make this happen.

What do you think? Please scroll down (or click) to post a comment. Or please share the post with your thoughts on LinkedIn – and follow me or connect with me there.

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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.


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