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Michigan Medicine

A Minute with Marschall

A 360° View of High Reliability (click here to see more)

November 18th, 2019

At a recent Town Hall meeting, one of the areas we discussed as a strategic priority for the organization is improving value through improved safety. One of the most important initiatives we will undertake is for all of us to be participate in high reliability training, during which all of us will learn Universal Skills. 

The concepts of high reliability and the Universal Skills that are foundational to reducing errors are basic and simple. They are fundamental behaviors that anyone can choose to practice — things like asking for clarification, raising a concern, and taking a moment to double check and confirm you’ve got it right. Whether in a clinical setting, or a support area like Finance or Human Resources, these behaviors in some way affect our ability to deliver the best care possible. These principles and practices are seemingly so basic, but can be the difference between life and death.

Many of us can cite instances where you, or a friend or family member have been harmed due to medical error. These are powerful examples that support high reliability training and speak to the immense power of small actions.

One instance I encountered before coming to Michigan involved a young couple expecting their first child. The labor had been prolonged and difficult. During labor, the decision was made to administer a common intravenous sedative that came in a red-topped vial.

The couple was resting, the room was darkened and the person administering the medication did so and left the room. Within a minute or two, the woman became short of breath and shortly thereafter could not move and stopped breathing. Her husband, a physician, recognized this and called for help while administering CPR. Fortunately, the paralysis she experienced resolved within a minute or two.

What had gone wrong? Root-cause analysis revealed that the person administering the medication had mistaken a vial of a powerful paralytic medication used in surgery (succinylcholine) for the sedative. That person had not double checked the medication with another care provider prior to administering, as is policy. Additionally, the two medication vials were indistinguishable, and were not labeled.

The baby and mother are fine today, but that family will likely always live with the “what ifs” in that scenario. One small action – confirming the contents of an unmarked vial of medication – would have prevented what could have turned into a devastating tragedy for a young couple, just starting a family.

We often speak of safety in terms of our patient outcomes, but there is a looming domino effect that hits families, the community, the health care providers and the support staff.  We need to think about how we can protect all of these constituents from experiencing the emotional and mental toll of patient harm. That is what high reliability and Universal Skills training are all about.

In January 2020, we will expand the high reliability training to reach all of our employees over the ensuing six months. I hope you will take this training to heart. Regardless of where you work at Michigan Medicine, this is an important initiative for all of us. Sometimes we don’t realize how interconnected we all are, but it really does take the entire, united village to provide the best possible patient care.