How A System’s Approach Can Change Safety Culture

 Annie’s Story

A remarkable video is making the rounds of healthcare circles.  In it, Annie, a nurse at MedStar Health describes her role in a patient incident involving a glucometer. Annie read the word “high” on the screen and treated the patient accordingly.  In fact, the patient’s blood sugar was critically low, and the mistaken treatment landed the patient in an intensive care unit.

In making the video, MedStar said it wanted to confront the “shame and blame” response that typically accompanies patient incidents: Look for a scapegoat, instead of addressing the broader system issues that likely led to the problem.  In this case, there were apparent human factors and design issues that needed to be addressed.

“It was probably the worst experience I’ve ever had in my professional career,” Annie says in the video.

Response to the video has been overwhelming, with many viewers applauding MedStar for its transparency and posting comments online saying it demonstrates the kind of approach more healthcare organizations should embrace if they are serious about patient safety.

CLICK HERE  to view this 5 minute 34 second YouTube video.

From: AAMI News June 2014