This past month I was lucky to attend the Institute for Healthcare Improvement’s (IHI) Patient Safety Congress. Over the course of a few days, I listened to experts from around the world weigh-in on current issues facing healthcare.
For background, the IHI was officially founded in 1991, and is a non-profit organization dedicated to improving healthcare globally. It is made up of individual members as well as organizations that seek to share knowledge and research to improve our healthcare systems. Besides bringing people together to learn and grow, the IHI works with other expert organizations to develop its own literature and guidelines.
For me, leaving direct patient care to work at Keriton has shone a bright light on the importance of a strong quality and safety framework. We’re a company founded on the premise of safety by eliminating all forms of feeding errors, but we also focus our platform on improving quality outcomes by increasing human milk exposure for vulnerable children. Safety and quality walk parallel paths that often intersect, and that fact could not be more obvious in the time I’ve spent working with new hospitals to implement the Keriton system.
Planning and executing the deployment of Keriton touches all parts of a hospital; its success is dependent on the strong safety/quality culture of an institution.
In the course of transitioning to our system, we meet and interact with stakeholders at all levels of the hospital hierarchy. A pediatric feeding system may seem like a small piece of technology, but to be effective, it needs the approval and support of:
- Hospital-Level Leaders
- Department-Level Managers and Directors
- Medical Directors and Providers
- Supply Chain Managers and Staff
- Both Local IT And EMR Support Teams
- Dietitians and Nutrition Services
- Lactation Consultants
- Patient Care Technicians
- Unit Secretaries
The teamwork required is immense and only possible when all stakeholders care deeply about supporting and improving their culture of safety.
Keriton may be just one spoke in the great wheel that is our healthcare system, however after listening to the speakers at the Congress, it is clear more than ever that improving patient care falls on the shoulders of everyone whose roles directly or indirectly touch patient care.
In the wake of the recent RaDonda Vaught case – a nationally covered trial that saw criminal charges brought against a nurse after a deadly medication error – the theme of the IHI Congress continually circled back to what constitutes a culture of safety. The overwhelming consensus from speakers and panelists was that practicing a safe culture means looking deeper to understand all the factors that contribute to a safety failure. Blame and punishment alone are rarely the answer to correct problems and affect change. A genuine culture of safety challenges us to face hard truths about our processes, formally investigate and identify areas of weakness, and then commit to real improvements through real action.
Scanning systems to improve feeding safety, especially when feeding human milk, have existed in many iterations for years. Still we’re often contacted by potential customers because they continue to struggle with feeding errors, even with a scanning system in place.
It would be easy to simply blame nurses and end-users for these continued errors, and in some cases, gross negligence may play a part. But, as was discussed at the IHI Congress, an established pattern of errors most likely indicates other factors are at work. Approaching improvement from a culture of safety perspective means acknowledging the need for process improvement as well as user compliance.
The hard truth is, healthcare workers are inundated with scanning systems and healthcare technology intended to stop errors. In the wake of the National Academy of Medicine (formerly the Institute of Medicine) report To Err is Human , healthcare as a whole accepted the role of human error in adverse events and endeavored to improve. As a way to mitigate that risk, new guidelines and new technology flooded hospitals and continues to expand exponentially.
So why – 20 years later, do preventable errors continue to occur?
A large body of emerging research shows that alarm fatigue in healthcare workers is real. Excessive alerts or false alarms have been shown to contribute to staff ignoring or missing real alarms when they happen. In some cases, work-arounds become common when technology is perceived as hindering patient care instead of improving it. Staff who lose value in the technology meant to prevent errors, stop using it. When remaining safeguards are removed? A risk-laden environment starts to unfold.
The hard truth is, technology only works insofar as the human being on the other end allows it to work.
At Keriton, we strongly believe that safe and effective healthcare technology is always a work-in-progress. I’m thankful our system was designed to consider the many challenges end-users face when they interact with our platform.
We proudly support a culture of safety, which means continually seeking feedback from customers/end-users and approaching our own design choices with flexibility and a critical eye. As was discussed at the IHI Congress, we believe good healthcare technology should always strive for high end-user compliance and proactively address areas of concern in real time.
Healthcare technology should never be stagnant. At Keriton, we view our product as an integral member of the healthcare team; and – as such – we hold ourselves to the same standards of evidence-based practice and quality improvement as our colleagues at the bedside. Hospitals are more than customers, they’re our partners. We will always strive to serve the individualized needs of institutions and staff to ensure our platform is valued and leads to improved safety and patient outcomes.
On the IHI’s website, they quote an Irish proverb:
When you come upon a wall, throw your hat over it, and then go get your hat.
The spirit of that proverb embodies the vision, mission, and values of the IHI and was clearly felt throughout the Patient Congress. They go on to write, “…this one little saying has inspired many big outcomes.”
I am proud to work for a company that also looks to accomplish big goals and create big outcomes. The team here at Keriton knows that these goals can only be achieved by cultivating and maintaining a true culture of safety. It is a core value of our company to never lose sight of our responsibility to the patients we serve as well as our responsibility to our partners in care who work every day to keep the children they care for safe.
Kelly Convery, BSN, RN, IBCLC, is the Clinical Quality Manager for Keriton. She’s a registered nurse and has worked in health care for over 15 years. She’s spent the majority of her nursing career in the Neonatal Intensive Care Unit and has been active in quality improvement projects and implementing best practice initiatives throughout her tenure.