Safety does not improve by chance

It was 2 am on a fall morning. My husband, Dan, and I were traveling in our new car on the newly repaved Wisconsin Highway 42 toward our trailer in Egg Harbor, Door County. Dan was at the wheel. We were both concentrating to keep each other alert for the last leg of the trip. Sarah, my 15-year-old daughter, was sleeping in the back seat. Out of nowhere, a pair of bright headlights appeared speeding rapidly toward us in our lane.

Out of the corner of my eye I saw Dan calmly make a quarter turn of the steering wheel directing the car smoothly into the shoulder as the car—“swish”—passed by, barely missing us. Then he turned the wheel back and the car went right back into the proper lane just as smoothly. We continued on our way. My daughter woke up and asked what happened. “Dan just saved our lives.”

This was a true near miss that could have been a hit. Maybe it was a stroke of luck or divine providence but I believe there was more than that behind this narrow escape. A number of factors saved us. Skill, attentiveness, experience, judgment, good conditions and proper equipment all played major roles. We were both alert in spite of the late hour. Dan was a skilled operator, an experienced driver with excellent judgment. We had made a conscious decision to have him drive instead of me in this very late and tiring journey. Our new car was an excellent piece of equipment. (An older, less-reliable car may have failed to respond properly.) The road was newly repaved and well maintained. All these factors helped to ensure our ultimate safety.

In health care it is the same as it was for us in that early morning journey. It takes skill, education, training, judgment, optimal conditions and proper equipment to avoid safety events. It is no accident that some hospitals are safer than others. Organizations that pride themselves on being prepared for unexpected circumstances to avoid harm to patients do the best in creating the safest environment. In addition, they have systems in place to learn from the incidences where there was a break in the safety net.

We have worked hard at Advocate Good Samaritan Hospital to create a culture where safeguards are in place to prevent errors. Timeouts for procedures, reporting of safety events and near misses as well as cultivating improved communication between health care providers/workers are some of the ways we have done this. However, what will it take to continue to get better?

It will take continuously looking at what we can do every day to reinforce these systems. It will take us looking at the breakdowns as they occur and proactively reporting them so that they can be prevented in the future. Our goal is no less than to be the safest hospital in the country.
I want to remind you that if you see a breakdown in patient safety, whether it has caused a poor outcome or not, there is still value in capturing it to prevent future injuries. Please report near misses in you institution. Your feedback is essential to saving lives from lessons learned.

Kind Regards,
Barbara Loeb, MD