James Bagian, MD, PE, professor of Engineering Practice and Industrial and Operations Engineering at the University of Michigan College of Engineering, was honored as this year’s Safety Scholar at the start of the 8th annual Patient Safety Awareness Week (PSAW) at Mass General for Children (MGfC) from March 12-18. During Grand Rounds on March 14, Bagian, a former astronaut, presented his talk, “Patient Safety – It’s Not Rocket Science,” which provided insights on the meaning of patient safety and how cultural changes matter most when making hospitals safer for patients.
“Safety is about culture, not compliance. People naturally want to do what’s best for patients, so you have to identify what barriers are in place that keep them from doing so,” said Bagian. “It’s about ‘What does the patient want?’ Patients want to be safe and cared for. Then it becomes about ‘How do we get there?’ It’s about goals… which is to prevent inadvertent harm to patients while under our care.”
Changes to patient care to ensure a safe environment are most effective when they are made from a systems-wide approach, said Bagian. Focusing on fixing vulnerabilities within a system, rather than placing blame on an individual or team, leads to a safer hospital environment.
“Safety is not about who is culpable. Blame has no place in medicine if you want to make hospitals as safe as possible,” said Bagian. “Safety is about learning more about what happened and how to prevent events from occurring in the future.” He emphasized that safety is everyone’s responsibility, from nurse and doctors to administrative staff.
Bagian served as the Chief Patient Safety Officer and is the founding director of the National Center for Patient Safety in the VA Hospital system and the Center for Healthcare Engineering and Patient Safety. He is a member of the following organizations: National Academy of Engineering; National Academy of Medicine; the Department of Defense Health Board and Trauma and Injury Subcommittee; and the NASA Aerospace Safety Advisory Board. He is a former NASA astronaut and has completed two shuttle missions. Bagian also investigated safety issues related to the Challenger and Columbia space shuttle disasters.
Other PSAW events included the following events:
- A keynote address from Bagian on RCA2, or root cause analysis and action, and display tables in the White lobby. RCA2 is an innovative process Bagian helped develop with the National Patient Safety Foundation that helps teams determine the root cause of a safety event and develop appropriate strong actions to prevent it from happening in the future.
- The MGfC Safety Star breakfast, in which eight MGfC staff were recognized for their efforts to “speak up” and improve the safety and quality of care provided to pediatric patients. This year’s Safety Stars were:
- Heidi Abendroth, RN, of Pediatric Hematology and Oncology
- Maureen Boyce, RN, of Adolescent and Young Adult Medicine
- Sandra Greene, RN, of Perioperative Services
- Christina Liberty, RN, of the Neonatal Intensive Care Unit (NICU)
- Karen MacCormack, RN, of the NICU
- Joanne Prendergast, RN, of Ellison 17/18
- Karen Turner, OT, of Occupational Therapy
- Nicole Simon, EdM, LABA, BCBA, of the Lurie Center for Autism
- Since October 2016, the MGfC “Good Catch Recognition Program” has recognized recipients who identified a potential safety concern before it reached a patient. Recipients included:
- Arianne “Cuff” Baker, MD, resident
- Katherine Bonsall, RN, of Perioperative Services
- Lisa Brugnoli-Semeta, RN, of the MGH Back Bay HealthCare Center
- Sarah Calderone, RN, of the NICU
- Carla Dale,PharmD, of the Mass General Pharmacy
- Michael Diviak, PharmD, of the Mass General Pharmacy
- Kelly Gardner, MD, resident
- Jaime Griffin, PharmD, of the Mass General Pharmacy
- Susan Hata, MD, of the MGH Back Bay HealthCare Center
- Elsie Hong, PharmD, of the Mass General Pharmacy
- Katie Kalogeris, RN, of the NICU
- Patricia Kent, RN, CPNP, of Pediatric Hematology and Oncology
- Erin Kivlehan, RN, of the Pediatric Intensive Care Unit (PICU)
- Christina Liberty, RN, of the NICU
- Amanda Manoogian, PharmD, of the Mass General Pharmacy
- Joanne Prendergast, RN, of Ellison 17/18
- Karen Ratto, RN, of the PICU