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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


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Tags:  ASPPS Member Spotlight 

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Just Culture as a Foundation for Joy in Work: The Impact of Leaders

Posted By Administration, Thursday, March 2, 2017
Updated: Thursday, March 2, 2017

What can health care leaders do to help reduce burnout among their colleagues?

by Barbara Balik, EdD, MS, RN


Burnout and lack of joy in work pose significant risks to health care organizations: 54% of US physicians are burned out and 33% of new nurses seek another job within one year. Burnout is a syndrome characterized by exhaustion, cynicism or depersonalization, and a sense of loss of personal effectiveness. This problem takes a personal toll on health care team members and also seriously impacts patient safety. The correlation between greater engagement and safer patient care is well documented. Reducing burnout results in improved quality, safety, and efficiency with lower turnover rates.

Joy in work occurs when all team members,

no matter their role, find meaning and

purpose in what they do.


Abundant evidence points to leadership behaviors that are an antidote to this significant problem. What leaders do makes a difference in reduced burnout, enhanced teamwork, lower turnover and safer care. 


Health care leaders can reduce burnout and achieve safer care by focusing on selected cultural essentials. Through the same leadership actions, they can get a two-for-one outcome: just culture and joy in work. Leaders who ensure just culture behaviors will nurture environments for both safe care and enable colleagues to find joy and meaning in work. 


Steps for leaders to integrate just culture and joy in work include:

  • Definitions of what are they are so everyone has a common understanding
  • Clear purpose statements of why they are important, which offers a clear focus
  • Actions that describe how we make gains in both



Just culture: a learning environment based on respect, trust, and fairness to achieve safe, highly reliable care.


It is an environment where:

  • Consistent clarity exists between human error in unreliable systems and intentionally unsafe acts.
  • Reporting and learning from system flaws and mistakes are the norm and are valued.
  • Safety science is used to understand human fallibility with systems designed to mitigate that fallibility.
  • Response to harm is not based on patient outcome.
  • There is confidence that it is safe to report and learn from mistakes.
  • Accountability is clear for all roles. (See Pichert et al. 2013.)

 In short, team members will know they will be treated respectfully, consistent with organizational values.


Joy in work: when all team members, no matter their role, find meaning and purpose in what they do. It results when colleagues have an intellectual, behavioral, and emotional connection to the organization’s mission (IHI in press). These environments are characterized by psychological safety. Psychological safety means an environment where all team members feel secure and capable of changing; they experience respectful interactions among all; are able to ask questions, seek feedback, admit mistakes, and propose ideas (Edmondson 2012).



The primary way leaders embed culture is what they pay attention to and how they react to critical incidents (Schein 2004). Leaders are responsible for paying attention to and developing organizational behaviors that promote psychological safety, which enables both engagement and safety.


For instance, of seven drivers of team engagement identified, three are greatly enhanced by psychological safety (Edmondson 2012):

  • Organizational culture and values are evidenced in the behaviors that are consistent with a just and fair environment. How leaders react to critical incidents involving patient harm is a key behavior that reflects consistency –or lack of– with the intended organizational culture and values.
  • Social support and community at work are illustrated by respectful interactions among all team members no matter their role. Members feel they can speak up without fear of retribution; are supported by colleagues and leaders to do their best; and experience a sense of camaraderie in their daily work. 
  • Workload and job demands show a balance between the work to be done and the time/resources available. Excessive workload is frequently due to ineffective systems that waste time, energy, and good will. These same ineffective systems lead to unsafe conditions.


As part of a well-designed leadership development process, leaders can ask the following organizational assessment questions to further advance their outcomes in safety and joy in work.

  • How well do we demonstrate just culture principles in every part of the organization? 
  • What happens when an error occurs?  What are leaders’ responses? Do the responses vary depending on level of harm or by what role was involved?
  • Are we as focused on much on system failures as we are on harm events?
  • Do we act daily to show that respecting others and treating them fairly is essential?
  • What fairness gaps do we have in our current actions?
  • Do we promote psychological safety through the following:

o   Be accessible, visible and approachable to develop relationships with team members.

o   Acknowledge the limits of current knowledge; frame the work as highly complex requiring all to contribute for great outcomes.

o   Be willing to show fallibility and humility; acknowledge that we do not have all the answers and are learning.

o   Invite participation.

o   View failures as learning opportunities.

o   Use direct, clear language.

o   Set boundaries about what is acceptable behavior and hold others accountable for boundary violation (Edmondson 2012).


This list of what, why, and how is a means of strengthening the leadership journey towards safer care and an environment where joy and meaning thrive.


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Do you find joy and meaning in your work? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.



Edmondson, A. 2012. Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy. San Francisco: Jossey-Bass.

Institute for Healthcare Improvement. 2017. Joy in Work White Paper. In press.


Schien E. 2004. Organizational Culture, 3rd Ed. San Francisco: Jossey-Bass



Barbara Balik, EdD, MS, RN, is co-founder of Aefina Partners and a longtime member of the NPSF Board of Advisors.

Tags:  burnout  culture  workforce safety 

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Sleep Deprivation, Health Care Providers, and Patient Safety

Posted By Administration, Friday, February 17, 2017

Fatigue can compromise the safety of patients and the health care workforce.

by Joanna Carmona

Landrigan, MD, MPH


Medical residents working shifts of 24 hours or more make 36% more serious medical errors than those who are limited to working 16 consecutive hours, according to a 2004 study published in the New England Journal of Medicine.

Even with patient and physician safety in jeopardy over sleep deprivation and fatigue, there’s still much debate over reducing trainees’ hours. Some of the objection to duty hour limits comes from the idea that trainees need to work extra hours in order to gain clinical experience and that shorter shifts may cause harm due to the increased handoffs required.

To Christopher P. Landrigan, MD, MPH, research director of the Inpatient Pediatrics Service at Boston Children’s Hospital, director of the Sleep and Patient Safety Program at Brigham and Women’s Hospital, and associate professor of pediatrics and medicine at Harvard Medical School, however, the misunderstanding of this key issue is the jumping off point to start discussion and change.

In a 2013 interview in PSNet, Dr. Landrigan said that “the trick is to implement changes in work hours in concert with concentrated efforts to improve the handoff process, teamwork, and infrastructure. Doing so can address fatigue-related errors without necessarily leading to a substantial increase in handoff errors. The net result can indeed be one where fatigue-related errors are reduced and handoff errors are not increased either.”


Dr. Landrigan has a wealth of experience on this topic and is the featured speaker for the National Patient Safety Foundation’s next Professional Learning Series Webcast, Sleep Deprivation, Health Care Providers, and Patient Safety, on February 27, 2017. He has led numerous landmark studies on the epidemiology of medical errors and adverse events, and interventions designed to reduce their incidence. His most important work has been focused on developing reliable patient safety measurement tools, and improving the organization of residency programs and academic medical centers. Dr. Landrigan’s work has contributed to national changes in resident work hour standards.

In 2011, the Accreditation Council for Graduate Medical Education (ACGME) created a set of requirements stating that duty periods of PGY-1 (Post Graduate Year One) residents must not exceed 16 hours in duration. Most recently, however, ACGME is in the midst of a re-review of the requirements with the intention of deciding whether or not to revert these requirements, allowing PGY-1 residents to take on 28-hour shifts like their more senior colleagues.

We know that when restrictions on shift hours are put in place, residents report that their quality of life improves and the rate of serious medical errors is reduced. We’ll discuss this and much more on the relationship between health care provider work hours, sleep deprivation, and patient safety. Please join us for this timely discussion.


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Tags:  fatigue  medical education 

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Member Spotlight: Adrian White

Posted By Joanna Carmona, Thursday, February 2, 2017
Updated: Thursday, February 2, 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

Adrian White is a member of ASPPS


Adrian White, RN, MBA, CPPS, Ambulatory Safety Outcomes and Performance Improvement Director

University of Texas Southwestern Medical Center

What are the biggest patient safety challenges you face at the University of Texas Southwestern Medical Center?

“The greatest challenge I face in my role at UT Southwestern is understanding the diversity of services we offer on our campus. Like many other academic medical centers, we deliver an array of services with various requirements from a regulatory and accreditation perspective. Outpatient and ambulatory areas are a melting pot for this diversity, resulting in slightly different ways of doing things in clinics that are on the same floor, or even share the same waiting area, but fall under a different governance structure.  


"While safety is a common thread in all of these areas, we need to ensure that a level of consistency exists in our practices. To address these challenges, a group within our organization, representing a wide variety of key stakeholders, spent six months creating a strategy document to build a comprehensive safety plan with a focus in the ambulatory and outpatient areas. While we recognize how different each department is, it is important for us to ensure that we are all connected and working collaboratively.”


"We need to have an openness of mind and heart that errors occur, despite our best intentions."

—Adrian White

Tell us why you chose to become a member of ASPPS?

“I wanted to become a member of an organization with a tried-and-tested history in patient safety. NPSF has its finger on the safety pulse, and the resources it provides helped me from a practical viewpoint in framing our outpatient safety plan.


"It also allows you the opportunity to build a support network of safety professionals around you. I have used the NPSF message boards to ask patient safety questions and I’ve had multiple people respond, many of whom lived through the same situation and have the bruises to show for it. Instead of reinventing the wheel, these colleagues have given me something to consider and adopt to my own situation.”

What made you interested in joining the patient safety field?

“The first stems back to my nurse training. One of my best friends through nursing school was involved with a medical error while we worked together in orthopedics. How everything was handled after the incident occurred really upset me, and our group. There was a lot of finger pointing and blame, when, in fact, there were multiple processes that weren’t followed. For weeks I wondered ‘where were the stop gaps to prevent us, mere students, from falling into traps.’ It was a positive outcome in the end, but the incident really stuck with me.


"Fast forward a few years and at 24 I became a nurse manager in Ireland who thought he knew everything. But I made a drastic medication error, too. The patient was fine in the end, but my actions could have killed him. This made me realize that an overdose of self-confidence will set you up for failure, and your world can come crumbling down at any moment with potentially disastrous consequences. These two personal experiences made me think: What is patient safety all about? Since then, the investigator in me is always asking ‘how’ and ‘why,’ and safety issues have plenty of answers to share.”


What keeps you up at night?

“When you talk with colleagues about a safety issue and they respond with: ‘That wouldn’t happen in my area’ or ‘Why would someone in their right mind do that?’, that apathy or arrogance worries me. We are all flawed individuals, and things will happen. We need to have an openness of mind and heart that errors occur, despite our best intentions.


"I also worry that people are afraid to speak up. When a safety event happens here at my institution, I want people to know that we should talk about it. I want them to hear someone say ‘You’ve done the right thing by reporting this issue. We just want to know what happened and to discuss ways to ensure that it won’t happen again.’ Having that openness and willingness to discuss these issues will make patients safer in the future.”


What is something unique about you?

“I am an immigrant. I came to the US from Ireland in 2008. My upbringing in Ireland and my training as a nurse in a very different health care system has helped me bring a diverse lens in reviewing issues I encounter working here in the US. Also, I have learned that my ‘brogue’ is a very powerful tool, and quite often my colleagues ask ‘How did you get away with saying that?’”



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Making Quality and Safety a Priority in Health Care for Our Children

Posted By Administration, Thursday, January 26, 2017
Updated: Thursday, January 19, 2017

New journal seeks to disseminate results of pediatric quality and safety work 

The first to focus solely on improving the medical systems that care for our most precious resource: our infants and children.

by Richard J. Brilli, MD, FAAP, MCCM


Dr. Richard Brilli


When the first medical journal was published in the United States, doctors were still debating the merits of bloodletting, anesthesia was an emerging concept, and the stethoscope had not yet been invented. By today’s standards, of course, medicine back then was still very primitive and physicians relied more on instinct in their practices than on collective knowledge.

In January of 1812, that began to change. That month, the first issue of the New England Journal of Medicine was published, and in its opening paragraph, editor Dr. John Warren called on doctors to be “directed by a knowledge of preceding discoveries.” Instead of practicing medicine as individuals, the publication encouraged doctors to document their experiences and share that information.

It was a milestone in American medicine. Publishing their experiences allowed physicians and researchers to accumulate knowledge, step-by-step, across a vast array of conditions. Soon, other journals were founded that focused on specific diseases and conditions. Now, more than two centuries later, we take another small but important step along that journey.

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Last fall, I was privileged to help launch the journal Pediatric Quality and Safety. While most peer-reviewed medical journals since the early 19th century have focused on disease, this is the first to focus solely on improving the medical systems that care for our most precious resource: our infants and children. Quality improvement (QI) was once only a peripheral concern for many organizations, but the time has come to make it a priority in pediatrics.

Though QI science has been maturing over the past few decades, it became apparent to me, as chief medical officer at Nationwide Children’s Hospital, that the pediatric perspective is unique. The mechanisms and types of injuries and preventable harm that children suffer while being cared for in the hospital, such as surgical-site infections and adverse drug events, are often different from those seen in adult care.

In an effort to address those pediatric-specific issues, our team at Nationwide Children’s Hospital developed an initiative called Zero Hero. The idea was simple: we needed to not only lower the rate of preventable harm and injuries in the children we care for, we needed to strive for zero instances.

The idea caught on, and in 2009 all 8 children’s hospitals in Ohio joined together to form a collaborative called the Ohio Children’s Hospitals Solutions for Patient Safety. Together, we followed the lead of Dr. Warren, freely sharing information about our experiences and openly debating and establishing best practices. Within the first few years, using QI science methodology, we attained considerable success in lowering preventable harm rates.

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So successful were we that the concept has gone national. Today, more than 100 children’s hospitals across the country have joined our initiative, working to eliminate 10 hospital-acquired conditions, including adverse drug events, catheter-associated urinary tract infections, central line–associated bloodstream infections, pressure ulcers, and ventilator-associated pneumonia, among others.

Since 2012, through May of 2016, the Solutions for Patient Safety Collaborative has saved 6,686 children from serious, preventable harm, which has led to an estimated savings of more than $121 million dollars in medical costs. That’s an average of saving more than 4 children from harm and more than $76,000 in costs every day, with a consistent upward trend each month.

We still have work to do, which is where this new journal will play a key role. As children’s hospitals everywhere strive to develop and deliver quality, evidence-based care, the journal will provide a perfect vehicle for collaboration. We will be able to collect and concentrate data and information from all over the world in one place, where it can be freely shared, easily disseminated, and rigorously debated.

It was this approach that proved so effective for Dr. Warren more than 200 years ago, and it’s time we dedicate the same focused efforts to safe and quality care for our children.


Pediatric Quality and Safety (PQS) is an international, peer-reviewed, open-access, online periodical that publishes results of quality improvement and patient safety initiatives that impact the lives of children. For details about submitting a manuscript visit the website.


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Richard J. Brilli, MD, FAAP, MCCM, is co-editor-in-chief of the journal Pediatric Quality and Safety and Chief Medical Officer at Nationwide Children’s Hospital in Columbus, Ohio.


Tags:  children's hospitals  patient safety research  pediatric safety 

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