Issue link: https://beckershealthcare.uberflip.com/i/824946
14 PATIENT SAFETY TG: I got into this area predominately based on my experience as an internal medicine resident. I had a great experience, but I saw things that could have been done better, and I got interested in the systems by which we can improve healthcare. I think my clinical practice was a major driver. I was seeing in my practice every day that things weren't going as well as they could. It's great to write papers, but unless it changes practice, then what's the point? So I got into the operational side of things, and that's been the focus of my career. Q: If you had to choose just one, which patient safety is- sue do you think should be of most concern to healthcare leaders today? TG: e biggest challenge is to make sure patient safety stays at the core of what healthcare leaders are doing because there are so many ways it could lose momentum. at to me is the number one issue, to have leadership stay focused on patients' safety despite all the changes that are coming at them. DF: I'm with Tejal on this one. Leaders shouldn't just choose one safe- ty issue to focus [on]. We have come a long way on patient safety, and we've done it issue by issue, project by project. We need to move to something that is more systemic. at's going to take some changes. It's going to require leaders to think about culture in their organiza- tion, collaboration and the need to tackle these issues and be willing to share and be more transparent. is is a mindset shi to make pa- tient safety a system property. Q: What achievement as a leader of your respective orga- nizations are you most proud of? DF: I'm very proud we've made this merger happen. Beyond the last 12 months, I look back with some satisfaction. We're starting to think about the absence of dignity and equity as safety issues that are harm- ful to patients. We've started to promote this and gotten some health systems to begin working on this issue. TG: I'm proud of the merger. is year marks NPSF's 20th anniver- sary. I'm very proud of this organization — the first organization to have sole focus on patient safety and that brought patient voice into the conversation. is predates me but it is something I'm very proud of. e work we've done around creating best practices has been really impactful in the patient safety space. We've had many organizations adopt these practices. Also, a report we did called "Free from Harm." I think that particular report was really a north star for us on how we're going to accelerate changes in patient safety. Q: What do you hope to achieve in the next year? TG: I think in the next year we are going to create a much larger and unified voice around safety. We're really going to integrate the resourc- es of our two organizations in year one so we can really feel like we're making a strategic impact on improving patient safety and working with a much more robust patient safety portfolio. So far we've been very reactive in healthcare. I'd like to see us address how to prevent harm in the first place and work to find ways to intervene before safety risks turn into harm. We need to move from reactive to proactive. DF: Tejal and I shared a realization that patient safety needs a reboot. is is the time for reinvigoration in the patient safety field. We want healthcare leaders to see patient safety as the No. 1 priority. I'd like to see us get patients and family much more involved in patient safety and feel more empowered in their care. I'd like to see the acceleration of progress in patient safety. Now is the time for acceleration. n Inappropriate Syringe Reuse Led to Hep C Transmission in Texas Hospital, CDC Says By Heather Punke A nurse in a Texas hospital mis- takenly believed saline flush prefilled syringes could be reused in separate patients' intrave- nous lines, which led to a hepatitis C transmission in 2015, according to a CDC Morbidity and Mortality Weekly Report released in March 2017. After coworkers observed the nurse leaving partially filled syringes near a computer work station, the hospital investigated the practice in collabo- ration with state, regional and local health departments and the CDC in October 2015. In an interview, the nurse reported reusing syringes in the previous six months, "erroneously believing that this was a safe, cost-saving measure if no fluids were withdrawn into the syringe before injection of the saline flush," according to the report. The hospital notified patients of the risk of bloodborne infections and of- fered free screenings for patients who may have been treated by the nurse during the nurse's employment from April 2014 to October 2015. Of the 392 patients who were po- tentially exposed, 182 (46 percent) completed all recommended testing. Those tests revealed one patient con- tracted hepatitis C as a result of the inappropriate reuse of saline flush syringes. "This investigation illustrates a need for ongoing education and oversight of healthcare providers regarding safe injection practices," the report concludes. "Hospital and other set- tings where injections are prepared and administered should perform routine audits. Syringe reuse, if iden- tified, should be immediately correct- ed and patient notification should be included as part of the institutional response." n "We need to move from reactive to proactive." — Dr. Tejal Gandhi