Today I attended the MedStar Quality and Safety Retreat, a quarterly gathering of physician and nursing leaders, patient safety experts, risk management leaders and clinical educators all focused on improving patient safety and quality across MedStar. The first lecture was by Paul Levy, the former president and CEO of Beth Israel Deaconess Medical Center in Boston. He led a major turn-around at the hospital and became a strong advocate for transparency of clinical outcomes and elimination of preventable patient harm. Mr Levy has written numerous articles and a book (Goal Play! Leadership Lessons from the Soccer Field) and author of a blog - he already posted his experience at MedStar (he is fast!). Check it out at:
The second speaker was our own Raj Ratwani, PhD. Raj is a senior scientist at National Center for Human Factors in Healthcare, a collaboration between MI2 and MHRI. Raj shared his vast experience as a behavioral scientist examining human behavior and safety in the airline industry and defense field and applied it to medicine (see picture of Raj giving the lecture below). His entire message is that we need to rethink the way we think about errors - they are to be expected! Below is an example of the data from a research study where the number of errors increase 10-30 fold with increasing number of interruptions. We need to accept that interruptions, workload, fatigue (as examples) will cause errors and only a systems approach will be effective to decrease these errors. It was very interesting and made me proud of how research will improve patient safety at MedStar.