Dr. Barrett Rosen
Ridley Barron’s Message Resonates at Baptist Hospital
Last month, Baptist Hospital hosted staff and colleagues from across Saint Thomas Health Services (STHS) to hear Ridley Barron’s perspective on patient safety.
“Sometimes we get lost in the numbers,” said Barrett Rosen, MD, associate medical director for Baptist Hospital. “Numbers can sound good; but when you put a face on it, it has a lot more meaning and impact. Each event represents a person. If we diminish our event rate dramatically, we diminish our death rate.”
Deborah Roberts, RN, director of Quality and Risk Management for Baptist, is passionate about safety and the story Barron shares. She has used his DVD in training sessions, and … like him … strives to humanize ‘events’ to remind staff that real people are harmed when processes are not followed.
A pilot site for the Safe Care initiative, Baptist Hospital was one of nine early adopters within Ascension Health to embrace this program, which continuously reminds staff of how critical it is to pay attention to the details and gives them the tools to stay on task. “You always want to keep safety in the forefront,” noted Roberts. She added, “Safe Care comes as a result of identifying problems and then putting in systems to keep them from happening again.”
Since Safe Care launched, the impact has been abundantly evident. “In three years, Baptist Hospital has seen an 80 percent reduction of serious safety events,” she said, adding the hospital defines those events as ones that cause death or permanent harm. The numbers are echoed across STHS facilities with a 72.6 percent reduction since system-wide implementation of Safe Care. “It’s hard to be that transparent with yourself,” Roberts noted, but added it was crucial in order to change the culture and mindset to safety above all else.
Should an error occur, that transparency extends to patients and families. “I want to treat people the way I would want to be treated if it was my family member,” Roberts said. “I do not go in with attorneys … ever … because of what happened with Ridley.” Instead, she said, the STHS culture calls for complete honesty.
Although safety has always been a priority for Rosen, he readily admitted his skepticism when the landmark Institutes of Medicine report, “To Err is Human,” was released a decade ago contending nearly 100,000 patients die annually of medical errors. “I looked at it and said that’s a bunch of garbage. They’ve extrapolated numbers. That can’t be real,” he recalled. Then Rosen was appointed to the Tennessee Board of Medical Examiners. “Suddenly I started seeing things in Tennessee that were more worrisome.” Still, he thought, “Well, it’s not in Nashville … not in my backyard.
“Then two or three years ago, I had a patient come in for hip replacement. It went wonderfully well, and I was really proud of myself. About midnight, I got a call from an associate that this lady had crashed and was being resuscitated.”
By the time Rosen arrived, the patient was on a respirator in the ICU and ultimately died. As he began trying to piece together what could have possibly gone wrong, he discovered she had been told by her family physician that she might have sleep apnea … information she didn’t share. The dangerous combination of pain medicine and sleep apnea can trigger cardiac arrest.
“That hit home,” said Rosen, “and it’s not just in Tennessee or my backyard or my hospital … I prescribed the pain medicine that ultimately led to her death.”
Although he had no way of knowing his patient might have sleep apnea, he was determined no other patient or provider would go into surgery without forewarning. Rosen devised a process to alert providers to the potential for sleep apnea and its resulting complications through a series of questions and the measurement of the circumference of a patient’s neck. If the condition is suspected, the patient is kept on special monitoring post-op and receives a less intensive dose of pain medication.
“Since that time, we’ve had no episodes of patients getting in trouble with pain medication,” he said. Rosen added the Joint Commission, whose representatives recently surveyed Baptist Hospital, requested program details to share with other hospitals.
“The Catch of the Month” initiative is another way to encourage physicians, care providers, and hospital staff to be on the alert for problems. Rosen said such issues almost always arise because of a deviation from best practices. Roberts added the hospital recognizes and honors those who intervene in these situations to catch mistakes before they reach patients.
“I’m passionate about this because there should never be another patient harmed,” concluded Roberts. “I’ll do anything I can to remind staff these aren’t just tasks … these are human lives.”