- Email: [email protected]
Being a Patient Safety Leader
Being a Patient Safety Leader
PAT I E N T SA F E T Y FIRST
SUZANNE C. BEYEA, PHD, RN, FAAN
I
n last month’s column, I listed six patient safety goals for perioperative clinicians. These goals include: • Be a leader in patient safety, regardless of your role. • Don’t be “just a nurse.” • Learn more about the science behind patient safety. • Place patient safety first in the provision of care. • Learn more about your organization’s patient safety initiatives. • Learn more about actions to keep nurses’ safe. Each column for the next six months will provide a more in-depth focus on one of these goals. This month’s column focuses on the first goal—that every health care worker should serve as a leader in patient safety, regardless of his or her assigned role. It is not just the nurse, physician, or individual who holds a formal leadership position who must advocate for patient safety. Every health care worker, from the OR manager to a member of the housekeeping staff, can identify a patient safety problem or concern. Consider the following hypothetical example: A patient is brought to the preoperative holding area by a perioperative nurse and is subsequently moved to the OR by the anesthesiologist. The surgical technologist who will be scrubbing for the procedure suspects that the patient brought in is not the patient scheduled to undergo this procedure. He alerts the circulating nurse, who compares the identity of the patient with the surgical schedule. They discover that the wrong patient indeed has been brought in. Because of the diligence of the surgical technologist, the mistake was detect-
© AORN, Inc, 2008
ed. In this situation, two potential wrong site surgeries were averted because one individual was willing to take the initiative to voice a concern.
DIFFICULTIES
OF
BEING
A
LEADER
Every member of the health care team should take on the role of a patient safety leader any time that safety may be compromised. Sometimes this can be difficult, especially when another team member is seen as the leader, either because of his or her formal title or an informal understanding among perioperative staff members. If, because of this perception, a nurse or other clinician hesitates to Every health care speak up or address concerns with a coworker, the worker, regardless of consequence could be injury to a patient. his or her position Many perioperative nurses can share personal in the facility, can stories about instances in which they found it diffiact as a patient cult to approach a physician about a safety consafety leader. cern. This hesitation may occur if the nurse believes that the physician “must be right,” or that he or she simply is “too difficult to talk to.” These beliefs may be the result of a past experience in which the nurse attempted to be assertive but was chastised by a physician colleague. Negative experiences can result in a nurse being hesitant to take on similar issues or concerns, either with the same physician or with another health care colleague. For example, a nurse may tell a surgeon that the surgical consent, surgical
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JANUARY 2008, VOL 87, NO 1
schedule, and history and physical are inconsistent regarding the correct surgical site. The nurse voices her concern, and the physician states in an emphatic manner, “Stop worrying. I’m the surgeon, and I know that the surgery is on the left side.” The nurse continues to protest, insisting that the site should be verified before the procedure is initiated. The surgeon brusquely responds, “Let’s get on with it—I have an office full of patients waiting to be seen.” When this type of exchange occurs, the nurse might be tempted to give in and allow the surgeon to continue with the surgery.
Leadership takes courage and a willingness to take the extra steps necessary to ensure patient safety and insist that everyone on the health care team take the safest action.
This is the critical moment for leadership to emerge. In this example, the nurse must become the patient safety leader. The nurse may need to emphatically and clearly state, “surgery cannot start until we are certain that the correct side has been clarified.” This type of leadership takes courage and a willingness to take extra steps to ensure patient safety and to insist that everyone take the safest action. To be a leader, each clinician must be willing to take risks and to act in the best interest of the patient and safe care. Such risks include the possibility of being wrong or receiving negative or hostile feedback. Nurses must stand their ground, not taking the path of least resistance. In this way, they uphold their professional responsibilities and serve as leaders.
SUCCESSFUL LEADERSHIP Leadership does not require a specific personality type or formal training. It can be as simple as being assertive and advocating for
222 • AORN JOURNAL
Patient Safety First
the patient. Successful leaders often achieve their goals by taking small, careful, deliberate steps to influence others to achieve a specific goal. In most situations, a nurse has the choice to be passive and accept the status quo or to be assertive and challenge the actions or statements of someone else. All clinicians must be willing to address safety concerns with each other, especially when a patient may be at risk. Most nurses do not hesitate to inform a coworker when he or she breaks sterile technique or contaminates the sterile field. In a typical exchange, the nurse might say, “I noticed that you contaminated your gloves. I have opened another package so you can change them.” Generally, these types of communications are factual, direct, and well received. Communications may grow increasingly tense, however, if the coworker angrily responds, “I didn’t contaminate my gloves.” In this situation, speaking up and persistence in advocating for the patient could be instrumental in preventing a surgical site infection.
WHOSE RESPONSIBILITY IS IT? No one should expect others to bear the responsibility or solve all of the problems that exist within complex health care systems. Working as members of a team, clinicians can address many of the error-producing conditions within a clinical setting. Health care providers often encounter hazards while providing care, but if clinicians fail to act and choose to wait for someone else to identify or address these error-producing conditions, patient injuries undoubtedly will occur. Following is an example of the danger of not taking action. In a small US metropolitan hospital, the members of an orthopedic team have noticed that many of the patients they care for are too large for the older surgical bed in the OR. Despite their observations, the members of the team ignore this concern. One day, a patient who is overweight is brought to the OR and placed on the bed for repair of a fractured hip. When the surgery is complete, the patient is left unobserved for a few moments just before he is transferred to the hospital bed. During this time, the patient accidentally rolls off the surgical bed, receiving
Patient Safety First
contusions to his shoulder and lacerations to his scalp. In this situation, if any member of the team had taken a leadership role and addressed the potential patient safety issue, the injury could have been avoided. First, members of the orthopedic team could have requested a new surgical bed to accommodate larger patients. Additionally, team members could have implemented other safety measures to protect larger patients on the surgical bed, such as using additional safety belts. Team members also could have agreed on a strategy to ensure that someone remains with every patient during his or her time on the OR bed. Each day, clinicians encounter situations that need to be corrected or conditions that could lead to a serious error. Nurses must monitor their environment actively to detect potential problems. To promote safety and avoid patient harm, nurses must address any problems they observe or report the problems to the appropriate person. Leaders are those who actively engage in this endeavor and seek to improve existing systems.
JANUARY 2008, VOL 87, NO 1
BE
A
PATIENT SAFETY LEADER
Leadership does not require a specific title or position—it is an integral part of every clinician’s role. Patient safety is not a job belonging to someone else. As individuals and team members, nurses are well positioned to be champions for patient safety, and every day there are opportunities to be a patient safety leader. Each person in the health care environment can identify opportunities to make a difference and increase safety. It takes courage to speak up or take on a challenging issue, but doing so will help ensure patient safety. Editor’s note: If there are additional patient safety goals that readers would like to recommend for this series, please share them with the column’s author by sending an e-mail to AORN at [email protected]. SUZANNE C. BEYEA PHD, RN, FAAN DIRECTOR OF NURSING RESEARCH DARTMOUTH-HITCHCOCK MEDICAL CENTER LEBANON, NH
Intestinal Microbes Show Complex Development in Infants
R
esearchers studying stool samples from 14 healthy babies during the first year of life have found that infants have varied, dynamic, and complex colonies of intestinal microbes, according to a June 25, 2007, news release from the Stanford School of Medicine, California. The research was carried out to investigate how microbes establish flourishing communities in what begins (ie, in utero) as a sterile environment. Parents of the infants collected stool samples according to a prescribed schedule (eg, first stool after birth) and during key events (eg, starting on solid food, taking antibiotics). All of the 14 infants in the study were delivered at term and were breast-fed. Six babies were given antimicrobial medicines at some time during their first year; however, only one of these infants showed a dramatic change in intestinal flora after receiving the medication. Two of the infants were fraternal twins and were the only ones delivered by ce-
sarean section. The twins had much lower bacterial levels than other babies during the first week of life, possibly because they were not exposed to the mother’s vaginal or rectal environments. They also had the most similarity in their microbial community profiles, which may indicate that genetics or environment factor into the development of intestinal microbes. The researchers determined that each baby had very different microbes colonizing his or her intestinal tract at different stages of development. By the end of the first year, each baby’s microbial colonization was complex, and the microbes were similar to those found in the intestines of adults. Baby poop gives Stanford researchers inside scoop on development of gut microbes [news release]. Stanford, CA: Stanford School of Medicine; June 25, 2007. http://med .stanford.edu/news_releases/2007/june/baby-bugs.html. Accessed July 10, 2002.
AORN JOURNAL •
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PAT I E N T SA F E T Y FIRST
SUZANNE C. BEYEA, PHD, RN, FAAN
I
n last month’s column, I listed six patient safety goals for perioperative clinicians. These goals include: • Be a leader in patient safety, regardless of your role. • Don’t be “just a nurse.” • Learn more about the science behind patient safety. • Place patient safety first in the provision of care. • Learn more about your organization’s patient safety initiatives. • Learn more about actions to keep nurses’ safe. Each column for the next six months will provide a more in-depth focus on one of these goals. This month’s column focuses on the first goal—that every health care worker should serve as a leader in patient safety, regardless of his or her assigned role. It is not just the nurse, physician, or individual who holds a formal leadership position who must advocate for patient safety. Every health care worker, from the OR manager to a member of the housekeeping staff, can identify a patient safety problem or concern. Consider the following hypothetical example: A patient is brought to the preoperative holding area by a perioperative nurse and is subsequently moved to the OR by the anesthesiologist. The surgical technologist who will be scrubbing for the procedure suspects that the patient brought in is not the patient scheduled to undergo this procedure. He alerts the circulating nurse, who compares the identity of the patient with the surgical schedule. They discover that the wrong patient indeed has been brought in. Because of the diligence of the surgical technologist, the mistake was detect-
© AORN, Inc, 2008
ed. In this situation, two potential wrong site surgeries were averted because one individual was willing to take the initiative to voice a concern.
DIFFICULTIES
OF
BEING
A
LEADER
Every member of the health care team should take on the role of a patient safety leader any time that safety may be compromised. Sometimes this can be difficult, especially when another team member is seen as the leader, either because of his or her formal title or an informal understanding among perioperative staff members. If, because of this perception, a nurse or other clinician hesitates to Every health care speak up or address concerns with a coworker, the worker, regardless of consequence could be injury to a patient. his or her position Many perioperative nurses can share personal in the facility, can stories about instances in which they found it diffiact as a patient cult to approach a physician about a safety consafety leader. cern. This hesitation may occur if the nurse believes that the physician “must be right,” or that he or she simply is “too difficult to talk to.” These beliefs may be the result of a past experience in which the nurse attempted to be assertive but was chastised by a physician colleague. Negative experiences can result in a nurse being hesitant to take on similar issues or concerns, either with the same physician or with another health care colleague. For example, a nurse may tell a surgeon that the surgical consent, surgical
JANUARY 2008, VOL 87, NO 1 • AORN JOURNAL • 221
JANUARY 2008, VOL 87, NO 1
schedule, and history and physical are inconsistent regarding the correct surgical site. The nurse voices her concern, and the physician states in an emphatic manner, “Stop worrying. I’m the surgeon, and I know that the surgery is on the left side.” The nurse continues to protest, insisting that the site should be verified before the procedure is initiated. The surgeon brusquely responds, “Let’s get on with it—I have an office full of patients waiting to be seen.” When this type of exchange occurs, the nurse might be tempted to give in and allow the surgeon to continue with the surgery.
Leadership takes courage and a willingness to take the extra steps necessary to ensure patient safety and insist that everyone on the health care team take the safest action.
This is the critical moment for leadership to emerge. In this example, the nurse must become the patient safety leader. The nurse may need to emphatically and clearly state, “surgery cannot start until we are certain that the correct side has been clarified.” This type of leadership takes courage and a willingness to take extra steps to ensure patient safety and to insist that everyone take the safest action. To be a leader, each clinician must be willing to take risks and to act in the best interest of the patient and safe care. Such risks include the possibility of being wrong or receiving negative or hostile feedback. Nurses must stand their ground, not taking the path of least resistance. In this way, they uphold their professional responsibilities and serve as leaders.
SUCCESSFUL LEADERSHIP Leadership does not require a specific personality type or formal training. It can be as simple as being assertive and advocating for
222 • AORN JOURNAL
Patient Safety First
the patient. Successful leaders often achieve their goals by taking small, careful, deliberate steps to influence others to achieve a specific goal. In most situations, a nurse has the choice to be passive and accept the status quo or to be assertive and challenge the actions or statements of someone else. All clinicians must be willing to address safety concerns with each other, especially when a patient may be at risk. Most nurses do not hesitate to inform a coworker when he or she breaks sterile technique or contaminates the sterile field. In a typical exchange, the nurse might say, “I noticed that you contaminated your gloves. I have opened another package so you can change them.” Generally, these types of communications are factual, direct, and well received. Communications may grow increasingly tense, however, if the coworker angrily responds, “I didn’t contaminate my gloves.” In this situation, speaking up and persistence in advocating for the patient could be instrumental in preventing a surgical site infection.
WHOSE RESPONSIBILITY IS IT? No one should expect others to bear the responsibility or solve all of the problems that exist within complex health care systems. Working as members of a team, clinicians can address many of the error-producing conditions within a clinical setting. Health care providers often encounter hazards while providing care, but if clinicians fail to act and choose to wait for someone else to identify or address these error-producing conditions, patient injuries undoubtedly will occur. Following is an example of the danger of not taking action. In a small US metropolitan hospital, the members of an orthopedic team have noticed that many of the patients they care for are too large for the older surgical bed in the OR. Despite their observations, the members of the team ignore this concern. One day, a patient who is overweight is brought to the OR and placed on the bed for repair of a fractured hip. When the surgery is complete, the patient is left unobserved for a few moments just before he is transferred to the hospital bed. During this time, the patient accidentally rolls off the surgical bed, receiving
Patient Safety First
contusions to his shoulder and lacerations to his scalp. In this situation, if any member of the team had taken a leadership role and addressed the potential patient safety issue, the injury could have been avoided. First, members of the orthopedic team could have requested a new surgical bed to accommodate larger patients. Additionally, team members could have implemented other safety measures to protect larger patients on the surgical bed, such as using additional safety belts. Team members also could have agreed on a strategy to ensure that someone remains with every patient during his or her time on the OR bed. Each day, clinicians encounter situations that need to be corrected or conditions that could lead to a serious error. Nurses must monitor their environment actively to detect potential problems. To promote safety and avoid patient harm, nurses must address any problems they observe or report the problems to the appropriate person. Leaders are those who actively engage in this endeavor and seek to improve existing systems.
JANUARY 2008, VOL 87, NO 1
BE
A
PATIENT SAFETY LEADER
Leadership does not require a specific title or position—it is an integral part of every clinician’s role. Patient safety is not a job belonging to someone else. As individuals and team members, nurses are well positioned to be champions for patient safety, and every day there are opportunities to be a patient safety leader. Each person in the health care environment can identify opportunities to make a difference and increase safety. It takes courage to speak up or take on a challenging issue, but doing so will help ensure patient safety. Editor’s note: If there are additional patient safety goals that readers would like to recommend for this series, please share them with the column’s author by sending an e-mail to AORN at [email protected]. SUZANNE C. BEYEA PHD, RN, FAAN DIRECTOR OF NURSING RESEARCH DARTMOUTH-HITCHCOCK MEDICAL CENTER LEBANON, NH
Intestinal Microbes Show Complex Development in Infants
R
esearchers studying stool samples from 14 healthy babies during the first year of life have found that infants have varied, dynamic, and complex colonies of intestinal microbes, according to a June 25, 2007, news release from the Stanford School of Medicine, California. The research was carried out to investigate how microbes establish flourishing communities in what begins (ie, in utero) as a sterile environment. Parents of the infants collected stool samples according to a prescribed schedule (eg, first stool after birth) and during key events (eg, starting on solid food, taking antibiotics). All of the 14 infants in the study were delivered at term and were breast-fed. Six babies were given antimicrobial medicines at some time during their first year; however, only one of these infants showed a dramatic change in intestinal flora after receiving the medication. Two of the infants were fraternal twins and were the only ones delivered by ce-
sarean section. The twins had much lower bacterial levels than other babies during the first week of life, possibly because they were not exposed to the mother’s vaginal or rectal environments. They also had the most similarity in their microbial community profiles, which may indicate that genetics or environment factor into the development of intestinal microbes. The researchers determined that each baby had very different microbes colonizing his or her intestinal tract at different stages of development. By the end of the first year, each baby’s microbial colonization was complex, and the microbes were similar to those found in the intestines of adults. Baby poop gives Stanford researchers inside scoop on development of gut microbes [news release]. Stanford, CA: Stanford School of Medicine; June 25, 2007. http://med .stanford.edu/news_releases/2007/june/baby-bugs.html. Accessed July 10, 2002.
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