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Member Spotlight: Susan Mellott

Posted By Joanna Carmona, Thursday, August 10, 2017
Updated: Tuesday, August 8, 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 

Susan Mellott
   

Susan Mellott is a member of ASPPS

 

Susan Mellott, PhD, RN, CPHQ, FNAHQ

Associate Professor, Texas Women’s University

Could you tell us about your experience teaching patient safety to nursing students at Texas Women’s University?

I’ve been at Texas Women’s University full time since 2012 and realized a couple of years ago that there wasn’t much patient safety being taught in the undergraduate curriculum. I knew that we needed to put something in, so I started doing a research study where we embedded didactic as well as clinical patient safety concepts into the curriculum, and we’ve just finished our first semester. Students get the general patient safety overview and also discuss medical errors, near-misses, just culture, human factors, etc. Then the clinical faculty will observe them in a clinical setting, looking for things that either the students don’t do right or things they see nurses not doing right to take back and discuss in relation to those same concepts.

 

I also performed a needs assessment and found out that some faculty may not be fully up to date about patient safety. Some need to update their knowledge, others need greater confidence in teaching what they know.

 

What it comes down to is that we are redoing the entire undergraduate curriculum and there will be threads of patient safety throughout.

 

"They may think, 'Okay, we just have to keep the patient safe,' but it is far more than that."

—Susan Mellott

What made you interested in patient safety?

That’s easy. I cannot separate, as Don Berwick said at the 2017 Patient Safety Congress, patient safety from quality. I’ve always been involved with patient safety, but I see now that I’m teaching more of a need to move the courses over to the patient safety side. Human factors just keeps pulling me more and more into that and if I could keep working with human factors and patient safety, I’d be in seventh heaven.

How do we move forward to promote a culture of safety?

First of all, there are people who don’t understand what a culture of safety is. They may think “Okay, we just keep the patient safe,” but it is far more than that. Learning that Just Culture is a process, not the individual that makes mistakes, and that everybody will make a mistake at some point in time is so important. We need to look at the processes and refine those so that we prevent mistakes from happening or, if something does happen, we put in a safeguard to prevent it from getting to the patient. That’s one big factor.

 

People also fail to understand how you move from a basic mistake over to intended behavior and that there are different degrees as you move over. The way I teach it is: You know what you are supposed to do and you do it. But then you talk on the phone while you are driving with the idea that surely an accident won’t happen to me so you are willing to take that little bit of a risk. All of us in health care know that people find shortcuts and ways to get around doing things and so when we do that, we move into the same category as talking on the phone while driving. 

 

This year we are celebrating the 20th anniversary of NPSF. What do you think that means for the field of patient safety?

When Total Quality Management came out, no one knew what that was, but people were trying to put it into shape to have a quality culture within their organizations. Then in 1999, To Err Is Human came out, and many in the health care community said “Let’s drop this quality thing and get this patient safety culture figured out.” Many places still do not have a patient safety culture and they don’t have a quality culture either. The two things together, as I said before, I don’t think can be separated. The problem is that it has not been ingrained into a lot of organizations because the leadership focuses on other priorities like the financials, etc. However, with this being the 20th anniversary and with NPSF joining with IHI, people are going to take notice. To have the merger take place on the 20th anniversary is like a new celebration. 

 

 

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Joanna Carmona is communications coordinator at the Institute for Healthcare Improvement/National Patient Safety Foundation. Contact her at jcarmona@ihi.org.

 

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Member Spotlight: Sam Watson

Posted By Joanna Carmona, Wednesday, June 21, 2017
Updated: Wednesday, June 21, 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

 

Sam Watson is a member of ASPPS

Sam R. Watson, MSA, CPPS

Senior Vice President, Patient Safety and Quality, Michigan Health & Hospital Association

 

What are some of the main challenges for Michigan hospitals and health systems?

With regard to challenges related to hospitals and health systems and implementing both patient safety and quality activities, there’s so much to do. The opportunities to improve quality and safety are never ending. There is a tremendous amount of reporting burden that draws time and energy that, quite frankly, diverts attention from the work of improvement.

 

Patients are sicker than they have ever been in hospitals, and that draws the main focus of everyone. If you think about where improvement should happen, it shouldn’t be in the quality department or the safety department; it should be at the bedside. If you are caring for very sick patients, it’s one more thing to try to work into your day.

 

Could you tell us about your experience on the National Patient Safety Foundation Board of Advisors and what you look forward to as you make the transition to the IHI Board?

"If you think about
where improvement should happen,

it should be at the bedside."
—Sam Watson

Having the opportunity to participate in the NPSF Board of Advisors was a tremendous experience. To be surrounded by people who are so patient safety oriented and talented was a very humbling experience for me. I learned so much by listening to conversations around the table. The insights that people brought and the perspectives they had, you don’t get unless you are in that sort of environment. Looking ahead to the opportunity to serve on the IHI Board, again, it’s a very humbling thought considering the history of that organization and what it has brought to the world of improvement. To take that and magnify the work of safety in the NPSF mission is a tremendous opportunity.

 

What made you interested in joining the patient safety field?

My path to the world of patient safety was not direct. I’m actually a laboratorian, and my background is in clinical lab science, which is one of the few areas of health care that has been highly reliable, especially the blood blank. Quality is in everything we do. Transitioning into the quality and safety realm within the hospital setting, I found that the opportunity to influence care is profound in that you can bring everyone together to work on the problems of quality and safety.

 

As with many of us, there’s also personal experience—having a loved one who was affected by diagnostic error and to see what that meant to our family—that creates an amount of passion that you can only get, I think, by experience.

 

What is something that most people don’t know about you? 

Outside of the joy in doing the work I do, I race mountain bikes. I enjoy the adrenaline rush of hurtling through the woods on a single track and have been racing for over 25 years. As of late I have focused more on epic races, which are 50 miles or more.

 

The merger of IHI and NPSF took place as NPSF marked its 20th anniversary. What are your thoughts on that anniversary and how the patient safety field has changed?

Celebrating 20 years of the work NPSF has been doing is 20 years young. This is a nascent field. If you think back to 1999 with the IOM report, and of course Dr. Leape’s work before that, NPSF has created a vibe around patient safety, without which we wouldn’t have been propelled as far as we have. With everyone at the table, including providers, patients, and the medical device manufacturer community, I think that 20 years has resulted in so much change that otherwise wouldn’t have been accomplished.

 

You were a co-chair of the Board subcommittee that developed Call to Action: Patient Safety Is a Public Health Crisis and Patient Safety Requires a Public Health Response. Could you tell us about that experience? 

We had a subgroup of the Board of Advisors that came together and generated the Call to Action that, ultimately, the NPSF Board of Advisors and Board of Directors supported. The concept of this Call to Action is to raise awareness around the deficits that we still have in supporting patient safety work. To look at it as a public health issue is really unique from the standpoint of understanding that it’s not a doctor problem or a hospital problem; it is as critical as safe drinking water. Unless we magnify this issue to that level, it won’t get the attention or the resources it deserves.

 

To learn more about the American Society of Professionals in Patient Safety, visit www.npsf.org/aspps

 

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Joanna Carmona is communications coordinator at the National Patient Safety Foundation at Institute for Healthcare Improvement. Contact her at jcarmona@ihi.org.

 

 

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

 

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Member Spotlight: Jason Adelman

Posted By Joanna Carmona, Tuesday, January 10, 2017
Updated: Tuesday, January 10, 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 


   

Jason Adelman is a lifetime member
of  ASPPS

 

Jason Adelman MD, MS, Chief Patient Safety Officer, Associate Chief Quality Officer

Columbia University Medical Center/NewYork-Presbyterian Hospital

Board of Advisors, NPSF

 

What made you interested in joining the patient safety field?

 

“During my time as a hospitalist I became aware of the kinds of significant medical errors that can happen in a hospital. In one case of a wrong-patient error, an elderly woman was mistakenly given methadone through a series of systems lapses and ended up in a coma in the ICU. It was upsetting to hear of this error, but I also realized the potential for Health IT systems to protect patients from harm by keeping providers from making errors. This event really affected me, and further drove my interest to adapt our IT systems to reduce errors that could cause harm to patients.

 

“Given my interest in the field, when the time came for our hospital to name a patient safety officer, they approached me and I jumped at the opportunity to take on that role. There is more formal education now, but back then there were few opportunities for training in patient safety. I found my way to NPSF because it was the only patient safety organization with the focus I was looking for. I started attending and volunteering at NPSF conferences to learn as much as I could about patient safety. I’ve continued that learning in my position as chief patient safety officer and through my research into wrong-patient errors and Health IT safety. The luckiest thing in the world is to have your job not feel like a job, but be a true passion, and that’s how I feel about patient safety.” 

 

"It will be a long journey fraught with speed bumps and wrong turns, but if we keep designing and implementing safer systems,

Health IT will become as reliable as an ATM dispensing cash."

—Jason Adelman

What are some ways we can use information technology to prevent medical errors?

“I believe that eventually Health IT will make health care significantly safer and more reliable. It will be a long journey fraught with speed bumps and wrong turns, but if we keep designing and implementing safer systems, Health IT will become as reliable as an ATM dispensing cash. I believe Health IT will ultimately prevent diagnostic errors, medication errors, and generally help make healthcare reliable and safe.

 

“Some of the research I’ve done over the past several years has demonstrated how technology can help reduce errors. For example, I’ve created a metric to quantify wrong patient errors by developing an IT tool that looks for when doctors place an order on a patient, cancels that same order, and then places the exact same order for another patient. We would run this report twice a day and find at least 15 to 20 instances of potential wrong-patient errors each day, and then call the doctors involved and ask them what happened. Most of the time these events were confirmed as errors. We were then able to test interventions to reduce wrong-patient errors by using this metric. (See Understanding and preventing wrong-patient electronic orders: a randomized controlled trial.)

 

“In fact, we used this system for measuring wrong-patient errors to demonstrate that hospitals who temporarily name newborns Babyboy or Babygirl significantly increase the risk of placing an order on the wrong baby in their NICUs.  However, we were also able to demonstrate that if hospitals used more distinct temporary names that incorporates the mother’s first name, such as Wendysboy or Judysgirl, they can significantly reduce this risk.  This research was only possible because we had a reliable measure of wrong-patient errors.” (See Use of Temporary Names for Newborns and Associated Risks.)

 

Why did you become a member of ASPPS?

“I am passionate about patient safety. I want to continually learn as well as to share my experiences in patient safety, with the hope to improve patient safety beyond the hospital where I work. Being a member of ASPPS is one of the ways I use to connect with people.

 

“I am currently the chief patient safety officer at Columbia University Medical Center at New York-Presbyterian Hospital. I got this job because several years ago their quality and safety leadership read my article on wrong-patient errors. They got in touch and asked how I put the system together and I gladly shared everything I knew. I wanted them to have all of the information I had, so they could help patients at their hospital. Because of this, when there was a change in leadership they thought of me. I believe that when it comes to patient safety, we should all share what we know so that each person involved in patient care can contribute to making care safer for everyone.” 

 

What is something unique about you?

 

“I have four kids so there’s always activity in my house. I can see how distractions can lead to errors. In my case, right after dinner I often join my four kids in the living room to play a game. On occasion the children and I will leave food out in the kitchen, which is annoying to my wife. It’s not a life-threatening error, but we can all use a little help dealing with distractions and human errors.” 

 

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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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