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Member Spotlight: Ricardo Aguirre

Posted By Joanna Carmona, Thursday, March 9, 2017
Updated: Thursday, March 9, 2017

The American Society of Professionals in Patient Safety (ASPPS) is a membership program for professionals

and others interested in patient safety. This is part of a series of member profiles. 


by Joanna Carmona 

Adrian White
   

Ricardo Aguirre is a member of ASPPS

 

Ricardo J. Aguirre, MD, physician anesthesiologist, South West Healthcare System

What are the biggest patient safety challenges you face as an anesthesiologist?

 

“Establishing and maintaining a culture of safety, at both the local and institutional level, is one

of the biggest patient safety challenges I face as a physician anesthesiologist. In reviewing sentinel events or even near-miss events, several of the top 10 occur in the perioperative environment. However, oftentimes the breakdown in the safety-net system occurs long before the patient reaches the operating room.”

 

When we read about anesthesia, it is referred to as one of the safest disciplines

in health care. What are your thoughts on this?

 

“One of the fundamental principles of providing safe anesthesia care is constant vigilance of the patient. We are taught this early on in our training and is the motto of our professional society. Vigilance, in conjunction with the technological advances that are available today in how we monitor our patients, has made anesthesiology one of the safest specialties in medicine. The feedback we receive from the various monitors is continuously integrated into our clinical assessment of the patient to help guide our medical decision making.

 

"As a result, physician anesthesiologists have made the medical care that is provided in hospitals safer. For example, in remote locations outside of the operating room where sedation is required for procedures, having an anesthesia care provider whose primary focus is on the care of the patent, provides the utmost protection that patients need and deserve. It allows the proceduralist to carry out the intervention while we keep the patient safe and comfortable, ensuring that the appropriate level of oxygenation, ventilation, and circulation is occurring.

 

"While it is well known that the safety of anesthesia has improved significantly over the last several decades, it is imperative to understand that anesthesia care is provided within systems—systems that are managed by humans, systems that are prone to error. Most often, it is a system malfunction that contributes to a mistake and subsequently to an unexpected outcome where patients are injured.”

 

"As a physician, I naturally placed the blame completely upon myself, but in reality, there was a series of missteps that occurred which contributed to the mistake."

—Ricardo Aguirre

Why did you choose to become a member of ASPPS?

“I became a lifetime member of ASPPS from the encouragement of an article in the Anesthesia Patient Safety Foundation’s newsletter. It is important for me to represent my specialty in this evolving field of medicine. Obtaining my professional certification in patient safety will enable me to broaden my knowledge base by learning the science behind patient safety, system issues, and human factors. It also holds me accountable to be a patient safety advocate in my professional practice and allows me to be a resource to my colleagues. The benefits of membership span from the vast educational resources available to the opportunities to collaborate and network with others who share a passion for patient safety.”

 

Could you tell us about the talk you are working on currently, The Anatomy of a Wrong-Sided Block?

 

“Several years into my professional practice in the community setting, I performed a wrong-sided block. Although the patient was not harmed, I was devastated, felt ashamed, and it really took a toll on me emotionally. This talk is a narrative on my experience, what I learned from it, the steps I took in disclosing the mistake to the patient, and the changes I made in my practice to prevent it from happening again. As a physician, I naturally placed the blame completely upon myself, but in reality, there was a series of missteps that occurred that contributed to the mistake. For example, at that time there was no pre-procedural consent form and the original schedule was incorrect, only to be changed moments before the surgery. Everyone, including myself, was in a hurry to get the case started on time and a proper procedure time-out was not done. Additionally, due to the culture of the environment, the OR technician was afraid of speaking out, even though he was sure it was the wrong side. My hope is that by sharing this experience, other practitioners will learn from my mistake, preventing it from happening to anyone else.”

 

In your opinion, how do you move forward to promote a culture of safety?

 

“As an individual, becoming a Certified Professional in Patient Safety is one way that I am promoting a culture of safety. Additionally, I believe that the stigma associated with medical errors must be removed. We have to acknowledge that we as humans are fallible, that medical errors will occur, and that we must take the necessary action to learn from those mistakes to prevent further harm. Lastly, we need to provide all members of the health care team with the appropriate feedback through interdisciplinary discussions, guidance on event debriefing and disclosure, and the sharing of personal stories. All of these are crucial to promoting a culture of safety.”

 

 

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Joanna Carmona is communications coordinator at the National Patient Safety Foundation. Contact her at jcarmona@npsf.org.

 

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