Personal thought with patient safety culture

We all know that all healthcare providers have good intentions to work in healthcare to do good and no harm. However, healthcare mistakes or medical errors persist. Therefore, patient safety is integral to good patient care because it creates a complex multidisciplinary supporting system to guarantee quality care beyond the acknowledgment of medicines and advanced medical technology regardless of where, when, or how health care is provided. 

When looking back throughout my life in medicine journey, I have experienced several medical care delivery in different contexts, from a rural small community hospital or tertiary referral hospital in Thailand and several US children’s hospitals to a community-based residency training hospital in the Bronx, NYC, where I am currently working. Human error is undeniably caused by many intrinsic factors such as exhaustion from long-hour shifts, interpersonal factors such as distraction from coworkers on a busy day, ineffective communication, or even poor designed healthcare system. One thing that I have learned is how we respond to our mistakes and how we make them better.

More specifically, many admitted children with a diagnosis of pneumonia could develop a common complication, acute respiratory distress, or failure. Many healthcare settings did not have effective strategies to monitor respiratory status during critical times, such as during transportation or nighttime. But when bad things happen, such as poor oxygenation or respiratory compromise, how would all health care providers in different team members like attending staff, residents, medical students, senior nurses, junior nurses, or respiratory therapists respond to the situation?

In a hostile culture workplace, it is easy to find someone to blame. It could be a night shift nurse who did not check pulse oxygenation for several hours at night or an on-call resident who did not take proper actions with low oxygen saturation while managing a busy night call. It is pushed to be one’s responsibility to be competent in a fragile situation without any supporting system.

On the other hand, in positive work culture, the flawed system is the one to be fixed or corrected to make it better or not happen again. Children with pneumonia who have poor respiratory scores with impending respiratory distress would be monitored more frequently by bedside nurses and night residents. An effective sign-off system would be emphasized or applied to all intra- and interprofessional teamwork. Moreover, in patient-center healthcare culture, patients and families would be involved in each step of the discussion and have opinions on their care plan with respective healthcare decisions. 

We must accept that making errors is a part of our undeniable actions. Still, it is how we take accountabilities and improve them by preventing those mistakes systematically. It is not easy to change human behaviors or fix the medical system, but it does not mean it could not be better. It started with us, as a part of the medical healthcare system, to keep changing it better from the inside with the hope that we could mitigate medical errors and cultivate patient safety culture in the medical healthcare environment effectively and sustainably.