Acknowledgement, Education and Change are Essential for Success
By Thoralf M. Sundt, MD
The Mayo Clinic
I appreciate the editor's invitation to write the inaugural invited commentary for the STS Patient Safety section of www.sts.org. It is a special pleasure as I am personally greatly indebted to STS for introducing me to the subject and fostering my education as I have served as the chair of the STS Workforce on Patient Safety and Communications. This has proven an extraordinary opportunity to interact with passionately committed individuals as we explored, together, this nascent field. I have felt for some time that the surge of interest in safety and medical error was, in fact, good news for the practicing physician, as well as the patient. I am only more convinced of the same today.
I cannot help but reflect on my own initial reaction to the contention that medical error was a significant cause of morbidity and mortality. Having been quite literally reared in the traditions and culture of American medical care, I was at the same time disbelieving of the rather soft "data" put forth, and angered by what I took as an assault on my own performance and, but implication, my abilities and dedication. After all, I had worked hard and trained with the very best. How could the care I provided be faulted?
As my emotional reaction subsided rational thought ensued and I could recognize the validity of my challenger's arguments. Errors were made in care, by me and by others around me. Sometimes it seemed the system set me up to fail as well -- or was that just an excuse? Pride gave way to experience and I recognized that all too often I was re-living the same errors over and over again. And the impact of an individual such as Marc DeLeval cannot be overestimated. It was easy even for me to appreciate the unique value of his analysis of a cluster of surgical failures in the arterial switch operation presented a the AATS 73rd Annual Meeting in 1993, as well as his Honored Guest Lecture "Beyond Flatland" at the AATS 82nd Annual Meeting.
As a result of these and other input I have altered my clinical practice substantively. I have changed the manner in which I make patient care rounds, inverting the traditional order of speaking such that the usual hierarchy is inverted. By staring with the patient, then moving to the "lowest ranking" member of the care team and finishing with the highest, we encourage the individuals naturally least likely to speak up to do so. It has made the practice more patient-centered, and I am convinced more efficient, without making it unwieldy or complex. While other models may be even more inclusive, this simple modification, based on sound human factors principles, has improved my ability to care for my patients. In the operating room I have emphasized the importance of read-back/speak-back with my perfusionists, and I consciously thank anyone who raises a question about the procedure or a possible error. We are exploring the preoperative briefing as well, and have developed a formal research program in human factors at our institution.
The existence of this Patient Safety site and effort and investment it represents is but another example of he leadership provided by STS in enabling cardiothoracic surgeons to provide the highest quality patient care to every patient every day. As such it joins the STS National Database, as well as other efforts such as STS Guidelines as a resource for the individual surgeon to improve their practice. Like these other endeavors, it is the product of volunteer efforts by busy surgeons. The success of this site reflects the commitment of these individuals. I hope that each reader is able to use these resources to impact their practice, and that each of you finds your journey into this field as transformative as have I.
Please e-mail patientsafety@sts.org with your feedback or suggestions.
