HJBR Mar-Apr 2019

PSO 20 MAR / APR 2019 I  Healthcare Journal of baton rouge   Breaking the Silence Joan Stokes recalls vivid memories of an accident that almost ended her life 20 years ago and gives meaning and drive to her life-saving work today. While waiting to deliver her third child, Stokes prepared to receive an epidural-based anesthesia. “I hugged my nurse to ensure the correct position of the spine,” she said. “This epidural was different. It was painful. I asked the nurse and the doctor to stop, and they didn’t. I went into respiratory arrest, and they had to call a code. My placenta abrupted due to traumatic shock to my system, and I started losing blood rapidly. I lost half my blood volume in a very short period of time.” After surviving the ordeal with her newborn daughter, she remembers silence from the medical team. “Nobody wanted to talk about it.” Stokes helps hospitals make patient care safer and more reliable as a board member of the Louisiana Alliance of Patient Safety-Patient Safety Organization (LAPS-PSO) and system vice president of quality and clini- cal risk management at Lafayette General Health. She describes a different culture in healthcare at the time of her accident, when nurses would never have challenged a doctor or said stop and contrasts it with conversations she sees today. “We’re now at a point where we can have discussions about these events and learn from them, where everyone realizes that it’s not a department that’s over patient safety. It’s everyone’s responsibility. It’s okay to talk about these things. It’s vital that we have these conversa- tions and create a system of learning.” To Err Is Human A few years after Stokes survived her accident, the Institute of Medicine (IOM) targeted the danger- ous silence aroundmedical errors—both within and between healthcare organizations—in its bombshell report, To Err is Human. The report said less than five percent of known errors were being reported, largely because personnel fear they will be punished.  The IOM found that healthcare leaders often over- simplified their explanation of an adverse event, fix- ating on an unintentional human error while ignor- ing strong contributing factors hidden throughout a broken process. Blaming an individual does not change these factors, and the same error is likely to occur again. To expose system errors, the IOM rec- ommended voluntary, confidential safety-report- ing programs, like those in the aviation industry, to empower individuals to raise concerns without fear of retaliation. Effective reporting programs in other high-risk industries had already saved lives by prompting safety engineers to standardize an error-prone process or redesign unsafe equipment. The IOM also warned that fear of lawsuits pre- vented healthcare organizations from sharing solu- tions to common safety challenges. For example, a hospital that explored the root causes of an accident could not share these lessons with neighboring hos- pitals without increasing its legal risks. The report urged Congress to grant federal confidentiality and