Could this Happen in Our Practice?

What patient safety issue should you focus on during your next staff meeting, in-service training, or safety drill? Which scenarios pose the greatest risk for your patients? How best can your team(s) work together to preempt errors that expose you and your colleagues to allegations of negligence or malpractice?

A good place to begin understanding your vulnerabilities is by paying attention to someone else's poignant story, and then asking, “Are we prepared for a similar situation?” When such questions are raised in the workplace, you are likely to learn a great deal about your practice’s strengths and weaknesses. Even if only one person perceives a comparable risk, then you have a concrete opportunity for improvements in communication, clinical judgment, and patient care systems.

A team discussion about a specific patient safety risk will probably prove more fruitful than if individuals contemplate those risks independently. Some structure applied to that group exercise can further increase the likelihood that your team moves from conversation about system weaknesses to action toward making necessary changes to those systems.

Based on analyses of the Comparative Benchmarking System, CRICO has identified a series of Are You Safe? case studies that illustrate elements of office-based care where patients are most susceptible to medical errors. Each case study features a short synopsis and a brief analysis of the most significant system breakdowns in a familiar case scenario. Readers are then led through several practice assessment questions that offer providers a sobering opportunity to ask each other, “Could this have happened in our practice and where might our systems fail?”

For a practice truly committed to continuous patient safety improvement, a single case study and a 15 or 20 minute discussion has the power to heighten awareness of the problems that your patients are most likely to encounter, and initiate efforts to ensure that a similar event does not “happen here.”

Additional Material

• Patient Safety Assessment Tool