Agency for Healthcare
Research and Quality
(AHRQ) and the
Institute for
Healthcare
Improvement, among
others, as helpful
jumping-off points.
Since his organization
began promoting a
culture of safety, he's
been encouraged by
the results. For
starters, he's seen an
increase in reports of
near misses by frontline staff, as well as improvements in teamwork,
trust and overall safety awareness.
"The culture we should all be trying to build is one of reliability,
around the concept of following the same safety protocols with
every patient, every time," says Dr. Rothfield. "As good as we think
we are, we're not good enough till we have zero patient harm."
Reliability also means the same rules must apply to every individual,
regardless of rank or tenure. Say a frontline individual has the
courage to voice a safety concern that involves a high-profile surgeon,
but leadership responds by saying, "Thanks for letting us know about
this, but we need to make an exception this time."
"That's incredibly demoralizing," says Dr. Rothfield.
This is why, every 2 weeks or so, he speaks for an hour to a group of
new hires about patient safety. His goal: to let everyone know they have
his unflinching support. "At the end of the lecture, I ask them for their
1 3 6 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • A P R I L 2 0 1 7
• SMALL BITES Take steps toward a culture of safety by starting with individ-
ual "projects," such as reviewing medications to avoid potential dosing errors.
SURGICAL
ERRORS
