First Patient Safety Officer Works to Enhance Systems, Culture at Cleveland Clinic

When Shannon Phillips, MD, MPH, realized that common medical issues - such as hospital-acquired infections and medication errors - could be avoided by implementing better universal medical practices, she decided to learn how to make this happen. After graduating with a Master's of Public Health degree from Johns Hopkins University, she came to Cleveland Clinic's Children's Hospital, where she had performed a safety analysis as part of her thesis. Soon she was named Children's Hospital's first Patient Safety Officer and about a year later, became Cleveland Clinic's first Patient Safety Officer.

Why leaders are taking weekly walks

When the chairman of Children's Hospital asked what we could do to improve safety, rounding was a natural answer. However, leaders must see the value of walking around, talking to front-line staff and asking questions to get employees to talk about what went wrong and what we can do better. Last fall, senior leadership decided to begin rounding throughout the hospital. We now have 10 executives who have adopted 10 units. We will do more in the future.

Working to create a latex-safe environment

All patients, employees and visitors should be able to come into our facilities without exposure to latex, especially because each exposure increases your risk for becoming allergic to it. To avoid contributing to a latex allergy, we are working on main campus and throughout the hospital system to switch to latex-safe products. Surgical gloves were the first big piece, and they are about 50 percent converted at this time.

The importance of culture

We all have to help create a culture where employees can bring up issues when they need to. People know that if they tell me about a problem, I will pay attention and work with them to make the system safer. The first year I served as Children's Hospital's Patient Safety Officer, 43 percent more patient safety events were reported. This does not mean that we had more of these issues, but rather that our culture had changed.

Value of teamwork revealed in Safety Culture Survey
The survey conducted in March 2007 was very eye-opening. We had about 2,000 employees take it, but we need more participation in the future. What we found out is that employees feel like there's great teamwork in the departments or units where they work. However, between units, we need to find ways to act more like a team as we hand off patients.

Patient involvement is our responsibility

We strongly encourage patients to be involved in their care. One of the most important things is that patients know what medications they are taking and even better, carry a list with them at all times. If we are practicing medicine on a patient, rather than with a patient, we're not leveraging all of the relevant opportunities. We must engage them in the care process every day. It's about leading by example.

Dr Phiilips' Top 10

Lead by example.

Report all mistakes.

Communicate critical patient information consistently.

Limit the use of verbal orders - read them back and get them signed with a date and time.

Reconcile medications and allergies.

Sign and record the date and time on orders.

Write out the weight-based dosing when ordering medications for children.

Take a time-out before performing a procedure.

Identify your patients and their specimens.

Clean your hands.