CIR & HHC Join Forces for Safety

Conference Focuses on Improving Patient Hand-Overs

Workshops at the conference brought together residents, program and medical directors, nursing, IT, and patient safety administrators.

New York City public Health and Hospitals Corporation (HHC) and CIR joined forces on February 6th to host a first-ever conference on improving the transfer of patient information (also known as hand-overs). More than 100 conference participants took part—residents, residency and medical directors, nursing, IT and patient safety administrators — from HHC's eleven teaching hospitals.

Nationally recognized experts in the field of patient hand-overs addressed the conference. Dr. Christopher Landrigan, Sleep and Patient Safety Director at Boston's Brigham and Women's Hospital, presented data on how to optimize teamwork and safety. Medical errors usually occur because of a series of small failures, none of which are caught. Research shows that adverse events can best be avoided by improving systems. Standardized and computerized sign-out systems can substantially decrease the number of medical errors, and a checklist, much like a pilot uses before takeoff, helps to ensure that all the necessary information is recorded and available to the entire team, Dr. Landrigan said.

Dr. Edward Dunn, Director of Policy and Clinical Affairs at the VA National Center for Patient Safety, gave an animated presentation that included film clips and role playing.

Dr. Edward Dunn, Director of Policy and Clinical Affairs at the VA National Center for Patient Safety, presented on principles of safe transitions involving communication and teamwork culled from clinical experience. His use of movie moments, and actual clinical case studies, combined with role-playing brought immediacy, drama, and humor to the topic.

Speaking Up

Because hospitals are such hierarchical institutions, nurses and other providers too often don't feel empowered to speak up, which is ultimately bad for patient care, Dr. Dunn said. To combat this, he presented strategies for clear communication in the workplace. While organizing change can be compared to "herding cats," Dr. Dunn was ultimately optimistic about what can be achieved when organizations are willing to change.

Emphasizing the changes ahead, HHC's Executive Vice President, Dr. Ramanathan Raju said that, "we can no longer rely on an individual physician's memory and skill level, because we are all fallible. One individual is no longer captain of the ship "now we are a team of doctors, nurses, resident physicians and others, and anyone can stop the process if patient safety is in danger."

Alan Aviles, Esq.

HHC is perfectly poised to take advantage of new developments in the field and make changes in the way things are done because of its commitment to "being #1 in patient safety among all the nation's public hospital systems," said Alan Aviles, Esq., HHC's President. In connection with that goal, Mr. Aviles has committed HHC to transparency, going so far as posting mortality figures on its website, so the public can make informed decisions.

"I want to thank you for moving forward on the patient safety journey, and for your deep commitment to your patients," he said to all those in attendance.

Bringing It All Back Home

In the afternoon break-out session, attendees were grouped by hospital. They discussed how signouts are organized at their facility, what is working and not working about their current systems, and ways to overcome barriers to signouts that would be electronic and shared by all team members.

Dr. Spencer Nabors, a CIR NY Vice President who works at Kings County Hospital in Brooklyn, spoke for his group, and said that, "the most important item is to have open access to all.... There is no new system without a sense of buy-in from all members.Without that, we'll just be spinning our wheels.... The nursing staff needs to demand that we give them this info, too. That's a change in culture.

"There will be communication errors, but problems generate opportunities for change. As we heard today, 'Every system is perfectly designed to achieve the results we have,' and we need to create a new system. We have a wealth of highly committed individuals at all these hospitals. If each of us changes one thing after today"and I encourage you to do so"we will have accomplished a lot. As Leonardo da Vinci said, 'I am inspired by the urgency of doing.' This topic gives us all an opportunity to be inspired."