Becker's Hospital Review

9 THOUGHT LEADERSHIP Hospital CEOs: We stand with our front-line nurses and healthcare workers if they err By Robert Garrett, CEO of Hackensack Meridian Health and Kevin Slavin, President and CEO of St. Joseph's Health W e stand with our nurses and healthcare workers throughout the nation who are deeply trou- bled by the conviction of a nurse in Tennessee in the death of a 75-year-old patient due to a drug error. It's a rare and troubling example of a healthcare professional facing prison for a medical mistake. e conviction, based on the death at Van- derbilt University Medical Center in 2017, is alarming our care teams because it could set a precedent for future prosecutions. is case is a tragedy: a patient died unnecessar- ily; a family mourns; and a nurse carries all the blame when research and decades of ex- perience tell us that most medical errors are caused by faulty processes. is conviction could also have a chilling effect on practic- es that we know enhance safety and create a culture where people speak truthfully about missteps or mistakes and can count on being treated fairly. e 38-year old nurse has admitted her role in this mistake but insists the error occurred because of technical problems with an elec- tronic system that dispenses drugs. While she is facing up to eight years in prison, the hos- pital was not charged criminally even though evidence at trial indicated the medical center had a "heavy burden of responsibility'' for the error, according to media reports. It's important to note that states have different laws to address these tragic outcomes. In New Jersey, healthcare workers have greater pro- tections under the state's Patient Safety Act. As an industry, we have made major strides in patient safety since the Institute of Medicine re- leased the landmark report "To Err Is Human: Building a Safer Health System'' in 1999. Here's one great example: A 50 percent reduction in bloodstream infections in hospitalized patients from 2008 to 2014, according to the CDC. Our health networks align with the report, which launched a transformation in how hospitals report, address and prevent medi- cal errors. e findings are relevant two de- cades later: We cannot punish our way to safer medical practice. Criminal prosecutions for unintentional acts are the wrong approach. Healthcare has modeled the approach taken by the airline industry, which has drastically reduced fatal accidents through enhanced technology, improvements in air traffic con- trol and pilot training. Let us be clear: Our commitment to provid- ing a safe and high-quality healthcare envi- ronment for our patients and team members remains paramount. We continuously work to produce the best outcomes by creating more standardized practices and processes, rigor- ous reporting and monitoring of patient out- comes and building a culture that emphasizes quality and safety over blame and fault-find- ing. A culture of safety reduces harm and saves lives. Advancing safety begins with policies that protect team members for reporting mishaps and depends on our collective ability to learn from mistakes — whether human, technical or system-induced errors. is protection is reflected in the safeguards we have put in place to prevent falls and reduce hospital-ac- quired infections, medication errors and oth- er preventable events. We remind and encour- age our teams to report safety issues through an online link so we can enact strategies and processes to prevent mistakes from happen- ing again. Each safety event requires a system- ic review — without an automatic disciplinary action or punitive response. is commitment to safety is saving patients' lives. Hospitals have made major strides in reducing hospital-acquired infections, post- operative sepsis, falls and drug errors and other preventable events. In fact, New Jersey hospitals performed better than or equal to national averages for most patient safety indi- cators, the New Jersey Department of Health has reported. ere's no question that we have more to do, but let's not forget how we got here: by cre- ating a deep sense of individual and institu- tional responsibility in our hospitals and care locations, emphasizing fairness and transpar- ency in our reporting and support for our care teams. At a time when nurses and other front-line heroes are exhausted by two years of a pan- demic and are oen struggling with a chal- lenging public, let's remember we must have their backs. We do this by providing safe en- vironments for transparency, reporting and improving care processes. We are partners — hospitals and care teams — working col- lectively to provide the best outcomes for the patients we are privileged to serve. Robert Garrett is the chief executive officer of Hackensack Meridian Health. Kevin Slavin is president and chief executive officer of St. Jo- seph's Health. n Robert Garrett Kevin Slavin It's important to note that states have different laws to address these tragic outcomes.

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