Despite bacteria in labs, clean pharmacy report

In Behavior change, hospital, Patient Safety on October 31, 2012 at 9:15 am

Whenever a story comes out like this one regarding contaminated steriods causing meningitis and DEATHS, I cannot help but wonder whether our accreditation processes are majorly flawed. This is not intended to disprepect the amazing work of say the Joint Commission (their patient safety and quality journal is one of the best and their sentinel alerts have no doubt saved countless lives) however any kind of process such as theirs is going to encourage the hiding of deficits. Compare this with visits by a PSO such as ISMP and you get a totally different level of transparency.

I liken this to a court of law. On the witness stand the advice is to be evasive, answer only the question: don’t comment, add more info or compromise the case in any way.

This is sort of the same prep front line staff often get to be Joint commission ready. I am sure every institution has their own “survey tips” (example

Even the Joint comission tells you what to do

From an organizational psychology standpoint, it seems to me there is just no way that organizational problems will not be hidden in this type of survey. Staff will avoid surveyors, fearful that they will be “the one” who disgraces the organization. There is shame and blame inherent in this type of process. Staff do not usually speak with surveyors without a manager present.

Contrast this with a survey by a Patient Safety Organization where staff are encouraged to speak up and be truthful. They are allowed to speak to surveyors alone. Staff line up for opportunities like this: to share their concerns and frustrations. It seems PSOs are really the future of patient safety and not accreditation programs. Hospitals should be judged by their patient safety culture scores and their employee satisfaction scores. This would be much more enlightening as to whether or not an organization is safe for patients. Happy employees working in a safe culture are likely producing great outcomes.

Transparency and speaking up are two of the basic tennants of any safety program. I am sure many employees knew of the conditions in the compounding pharmacy. If only someone had asked them….in an open and non-threatening manner..

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