Features  |   May 2017
Culture of Safety – Building It Into Department DNA
Author Affiliations
  • Brett L. Arron, M.D.
    Committee on Patient Safety and Education
  • Keith J. Ruskin, M.D.
    Committee on Patient Safety and Education
  • Richard D. Urman, M.D., M.B.A.
    Committee on Patient Safety and Education
Article Information
Patient Safety / Features
Features   |   May 2017
Culture of Safety – Building It Into Department DNA
ASA Monitor 05 2017, Vol.81, 14-16.
ASA Monitor 05 2017, Vol.81, 14-16.
We all were introduced during residency to patient safety in various ways, often through the efforts of the Anesthesia Patient Safety Foundation. The first intro-duction to system safety after residency (Dr. Arron) came when a senior clinician in charge of our “quality” committee noticed a rash of epidural blood patches in thoracic and obstetric patients. They were linked to two clinicians who preferred one brand of epidural kits. Other department members used different kits since they judged the other epidural catheters too stiff and difficult to pass. When the epidural kits with the stiff catheter were removed from the hospital, the post-dural puncture headache (PDPH) incidence again became a rare event. By including the technology into his evaluation of clinical performance and adverse outcomes, he identified the likely problem, prevented future adverse events and improved the performance of the clinicians by removing the detractor.
1 Comment
May 6, 2017
James Philip
Brigham and Women's Health, Harvard Medical School
Culture of Safety should be in the mind of every administrator up the management chains that support anesthesia
If this article on Culture of Safety were read and followed, dissatisfaction by caregivers would be reduced or eliminated. If leaders of anesthesia, surgery, pharmacy, information technology, clinical engineering, plant engineering, and all institutional infrastructure groups followed the principles and practices described in this article, we would all work in a safe environment and be proud of it. Each time infrastructure impedes this process, dissatisfaction grows.
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