Patient Safety Culture and Communication

How I Practice Video Series
Peter S. Bernstein, MD, MPH, FACOG

HIP: Patient Safety Culture and Communication from ACOG on Vimeo.


Medicine today has become very complex. I like the quote that “Medicine used to be simple, ineffective, and relatively safe, and today it’s complex, effective, but potentially dangerous.” There’s one study from the intensive care units where they counted up how many medical interactions a patient had each day and there were nearly 200. And in those 200 interactions there were approximately three to five mistakes per patient per day. The labor floor is no less complex, nor the exam room nor the operating room, and we have to really be on guard to prevent these mistakes from happening. And to do that we need to be obsessed with patient safety. Mistakes are inevitable. Even the best doctors are going to occasionally make mistakes and the best nurses and the best medical students and the best residents and so we have to be obsessed with patient safety. Imagine if you were the patient; you would want to be treated that way, where the team worked optimally together. Important to this effort is improving communication between all the members of the team. Now, a physician who walks in the room and thinks they’re the most important person in the room is going to create an environment where the other members of the team may be a little bit afraid to speak up, as opposed to the physician who walks into the room and says something to the effect of “I’ve got nothing invested here. If you see something, say something and that way we’ll do what’s best for the patient.”

I like a story that happened in our hospital where we had a very good physician who was taking care of a woman who was very committed to having a vaginal delivery and the physician wanted to help her get that vaginal delivery and the nurse noticed that the tracing for the fetus wasn’t very good. But she had a history with that doctor, a history where the doctor had made her feel small, and so when she noticed the tracing was bad she was afraid to say something to the doctor. And when the doctor ordered pitocin the nurse actually said that there were no available pumps on the floor in order to avoid a confrontation with the doctor. A couple hours later the tracing became a disaster and they did a crash caesarian section for a neurologically injured baby. This is an example of a fixation error on the part of the physician and a failure of communication between members of the team.

So medicine today is now a team effort. We’re not practicing alone anymore and I try to create an environment where everybody feels free to speak up. And this is how I practice.


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