What is a hard stop? “Think about it,” Amy Bethel, MPA, BSN, RN, NE-BC, education coordinator for the OR Business Management Conference, urged this year’s OR Manager Conference attendees. “You all know what a hard stop is, and I know all of you have had hard stops. But how many times did we kind of have to go ahead anyway? We all have stories where we were overridden by a physician or by administration.”
Bethel began this new leader session with the above prompt the day after Marcus Schabacker, MD, PhD, president and CEO of ECRI, gave the afternoon keynote presentation titled “Where are we now with patient safety and quality?” In his keynote, Dr Schabacker compared the aviation industry with healthcare. “Why do we trust a stranger whom we know nothing about to fly us somewhere in a metal tube, but we don’t trust doctors in our own communities?” he asked. He was urging the audience to consider what the difference was between the two industries.
“If there’s an issue, an airplane will not take off,” he answered. “It doesn’t matter how minor the issue is, everyone follows the safety checklist. And no one—not the pilot, not the crew, not the airline CEO—no one can make that airplane take off until every item is checked off.”
That lesson stayed with Bethel, who shared her own story about a flight she was on that was delayed because the plane would not take off until an overhead bin was properly closed. “We could not move until they had found a solution for that overhead bin,” she said. “I was sitting there in that plane thinking, ‘Okay, now this is a hard stop.’” Healthcare also has hard stops, but some people are able to override them.
Lori Terry, MSN, RN, CNOR, CSSM, AVP of surgical Services, LifePoint Health, agreed as she continued this session. “Patient safety is always at the forefront of our minds as leaders,” she said. “But how do you gain that mindset if you’re a new leader?” Healthcare leaders make decisions every day that have a direct impact on patient safety, especially in the surgical environment. “Empowering your team to make—and respect—hard stops is critical at potential points of failure.”
Patients are harmed every day, Terry said. In “high-income countries,” one in 10 patients are harmed when receiving care. “One in 10, 50% of those are believed to be preventable,” she added. This sentiment was again an echo from Dr Schabacker’s earlier keynote. He said that Baxter, for instance, makes a billion infusion bags every year, and even a 0.0001% failure rate would mean thousands of defective bags. “A percentage of defective bags that low would still impact thousands of patients. Even that 0.0001% is unacceptable.”
Dr Schabacker spoke at length about how the biggest driver of errors in healthcare is the human factor. During her own session, Terry agreed. “Medication errors are a leading cause of avoidable harm,” she said. Citing data from 2019, she added that unsafe surgical care accounts for up to 25% of complications globally, with close to 1 million patients dying during or immediately following surgery.
How will these statistics improve? “It's about team empowerment, cultural safety, and leadership,” said Terry. “It begins and ends with leadership. You own the culture of safety in your department. How you present it, and what you do with your staff, will impact how your patients are cared for every day.”Read More >>