{"id":6182,"date":"2011-06-15T00:07:31","date_gmt":"2011-06-15T07:07:31","guid":{"rendered":"http:\/\/www.wapatientsafety.org\/?p=241"},"modified":"2019-08-02T22:40:27","modified_gmt":"2019-08-02T22:40:27","slug":"npsf","status":"publish","type":"post","link":"https:\/\/www.qualityhealth.org\/wpsc\/2011\/06\/15\/npsf\/","title":{"rendered":"On being a passenger on the way to the NPSF Congress"},"content":{"rendered":"

\"\"Welcome to the inaugural blog of the Washington Patient Safety Coalition!<\/strong> We welcome your\u00a0comments and suggestions for topics<\/a>.<\/p>\n

In May I had the opportunity to attend the National Patient Safety Foundation Congress<\/strong><\/a> for the first time.\u00a0 I\u2019ll share my two major impressions, one of which is directly related to the event\u2019s content and the other to the process of travelling to Orlando.<\/p>\n

First, regarding content:\u00a0 my overall impression is that we in Washington are far ahead of the rest of the country.\u00a0 It doesn\u2019t mean that we are perfect or that we are effectively addressing all patient safety issues; rather, over and over I heard activities, partnerships, and interventions described as \u201cinnovative!\u201d and \u201cnew!\u201d that many in our state have been engaged in for years.\u00a0 Washington\u2019s unusual is that we have a very long history of collaborative work among partners in quality and safety, in combinations and effectiveness not seen elsewhere. \u00a0This realization was both reassuring and distressing.<\/p>\n

Second, I flew to Orlando on my airline of choice, Alaska Air.\u00a0 It\u2019s literally been years since I\u2019ve been on another airline.\u00a0 Once we were all boarded at SeaTac, the pilot announced that we might even leave 15 minutes early (woo-hoo!), so I settled into my book and lost track of time\u2026until he announced that we \u201cmay have noticed\u201d that we were still at the gate. Well, I hadn\u2019t noticed that about 30 minutes had passed (it was a good book:\u00a0The Girl with the Dragon Tattoo\u00a0\u2013 no, nothing patient safety-related).\u00a0 He gave some explanation along the lines of \u201cA warning light is going off related to [something that sounded really important to me] and this light is in both the main system and the backup systems. Don\u2019t worry, the mechanics are on board working on it.\u00a0 We\u2019ll keep you posted.\u201d\u00a0 My immediate thought: \u201cWhat was that recent legislation limiting how many hours passengers can be kept on the tarmac–was it four or five? I\u2019ll worry about it if it doesn\u2019t get fixed soon.\u201d I returned to my book.<\/p>\n

About 15 minutes later:\u00a0 \u201cThe mechanics are still working hard on it\u2026they haven\u2019t figured it out yet\u2026they have their manuals\u2026\u201d\u00a0 Then I started getting worried: At what point would the pressure to depart (keeping on time, avoiding mass unhappiness of the passengers, make sure the crew didn\u2019t go over their work-hour limits) overwhelm the responsibility to do the fix, of whatever it was, correctly?\u00a0 How would the mechanics know that the problem was really fixed?\u00a0 What were they experiencing?\u00a0 Were they all well-trained and rested? Were they at the beginning or end of their shifts? Did they have the tools and information they needed?\u00a0 Were they getting any pressure\u2014either implicit or explicit\u2014to get things done \u201cwell enough\u201d to leave close to on-time?\u00a0 (Does this remind you of concerns that might arise with starting that OR case on time, discharging a patient to a SNF, waiting for an interpreter so that the plan of care can be discussed or a consent obtained, or maybe even washing one\u2019s hands?) And what exactly\u00a0was<\/em><\/strong> the problem that to me, being completely ignorant of airplane stuff, sounded very important?\u00a0 Maybe it only\u00a0sounded<\/em><\/strong> critical, and only to me. When I\u2019m on the plane, everything that\u2019s \u2018wrong\u2019 sounds equally important to me.\u00a0 Was it the equivalent of a broken brake-light on a car? \u00a0Yes, it should be fixed, but isn\u2019t going to keep my brakes from working well.\u00a0 Could the pilot have conveyed the information and updates in a better way to the passengers?<\/p>\n

Short-term outcome:\u00a0 Whatever the problem was, it was fixed to the satisfaction of somebody \u2013 the mechanics?\u00a0 The pilots?\u00a0 Who decided?\u00a0 Was it \u201cgood enough\u201d or was it perfect?\u00a0 What was the definition of \u201cfixed\u201d? We took off, flew, and landed safely, about an hour late.<\/p>\n

What I learned relative to patient safety:\u00a0 (1) People who work in our field know too much to be flying around alert and unsedated. (2) We need to be extra-mindful of the pressures on providers. (3) What and how we tell patients and their families is so very important.\u00a0 What if the pilot had said something like this: \u201cThere is a problem with System X, which does Y [decorative, important, very important, critical!] function on this plane. We have two well-rested and highly-experienced mechanics on board working on it. If they have any questions, they have other resources they can, and will, contact. They will not allow us to leave until both we\u00a0and<\/strong> they are satisfied it is safe to do so, no matter how long it takes and no matter how anxious we might all be to get to our destination.\u00a0 This is understood up and down the Alaska chain of command. If you have any questions about this, just put on your call light.\u201d<\/p>\n

I would have felt much better.<\/p>\n

Thoughts?\u00a0Share with me here<\/a>.\u00a0Miriam Marcus-Smith, Program Director, WPSC<\/p>\n","protected":false},"excerpt":{"rendered":"Welcome to the inaugural blog of the Washington Patient Safety Coalition! We welcome your\u00a0comments and suggestions for topics. In May I had the opportunity to attend the National Patient Safety…","protected":false},"author":3,"featured_media":6708,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[8],"tags":[],"class_list":["post-6182","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-the-safety-blog"],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/www.qualityhealth.org\/wpsc\/wp-json\/wp\/v2\/posts\/6182","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.qualityhealth.org\/wpsc\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.qualityhealth.org\/wpsc\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.qualityhealth.org\/wpsc\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/www.qualityhealth.org\/wpsc\/wp-json\/wp\/v2\/comments?post=6182"}],"version-history":[{"count":1,"href":"https:\/\/www.qualityhealth.org\/wpsc\/wp-json\/wp\/v2\/posts\/6182\/revisions"}],"predecessor-version":[{"id":6768,"href":"https:\/\/www.qualityhealth.org\/wpsc\/wp-json\/wp\/v2\/posts\/6182\/revisions\/6768"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.qualityhealth.org\/wpsc\/wp-json\/wp\/v2\/media\/6708"}],"wp:attachment":[{"href":"https:\/\/www.qualityhealth.org\/wpsc\/wp-json\/wp\/v2\/media?parent=6182"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.qualityhealth.org\/wpsc\/wp-json\/wp\/v2\/categories?post=6182"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.qualityhealth.org\/wpsc\/wp-json\/wp\/v2\/tags?post=6182"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}