Guest: Stephen Powell
Presenter: Neal Howard
Guest Bio: Stephen Powell, MS, is the chief executive officer and president of Synensis, a healthcare consulting firm dedicated to helping hospitals achieve zero preventable harm. He is a recognized leader in the development of practices, behaviors, and strategies to improve organizational outcomes and is a member of the development team that created the TeamSTEPPS teamwork and communication system for healthcare organizations. Powell has supported the success of More than 350 organizations in 11 countries to improve patient safety, quality, and the patient experience by creating a culture of safety. He earned a Master’s in Human Factors from Embry-Riddle Aeronautical University and is a graduate of the Naval Postgraduate safety school. He is a member of the American College of Healthcare Executives and the Clinical Human Factors Group.
Segment overview: Stephen Powell, coauthor of The Patient Survival Handbook and CEO of Synensis, a healthcare consulting firm, discusses how a lack of leadership and a culture of non communication result in medical errors that are sometimes fatal.
Health Professional Radio
Neal Howard: Hello and welcome to Health Professional Radio. I’m your host Neal Howard, glad that you could join us today. Our guest in studio today is Mr. Stephen Powell, the CEO and President of Synensis. He’s an international patient safety culture expert and a recognized safety and quality leader who leverages the power of safety culture, who drive results, develop high reliability teams, accelerate quality improvement and reduce medical errors. And he’s here with us to talk about his book “The Patient Survival Handbook” and also to give us a little insight into his company Synensis and how they help hospitals achieve zero preventable errors. How are you doing today Stephen?
Stephen Powell: I’m doing great Neal. Thanks for having me today.
N: Now you’ve co-authored a book called “The Patient Survival Handbook.” Could you talk a little bit about The Patients Survival Handbook? Why you wrote the book and some of the ways that the book helps patients to identify when a lack of communication is affecting their particular healthcare case?
S: Thanks Neal, yeah I’d be happy to. The Patient Survival Handbook really, the genesis of this book was really to turn the tide a little bit for the last decade our company Synensis has really been working directly with the healthcare professional. Everybody from senior leaders in hospitals, clinics, and health facilities around the US and the world for that matter really try to tackle all this issue of preventable patient harm. And in that work, it’s kind of obvious Neal that we’re missing the very important member of the care team and that’s the patient, the family themselves.
N: Uh huh.
S: If we were gonna try to make a significant reductions in these harm numbers, we believe that it’s as many as 400,000 Americans die each year as a result of preventable medical errors. And that makes it the third leading cause of death in the United States and we actually think that these numbers, maybe similar not the number themselves but that their leading cause maybe similar in other countries as well.
N: In your experience when we’re talking about this preventable medical errors and 400,000 people on average dying each year, are we talking about things that result in identifiable harm immediately? Or are we going and saying 10 years down the line a mistake was made and it’s just being discovered? Are we putting those numbers together or is there some type of separation when we’re doing the research?
S: No, yeah this is an annual number. And this data is deemed from samples of medical records that are sampled and looked at and there’s some scientific weight that we go about using this, there’s a tool that we’ve now begun to use and with using technology to grasp what the error really is, that this is something we intended to occur … So it could be an error of omission or an error of commission. So this could be something as simple as that we gave someone the wrong medication, it could be that it was meant for another patient but it was mistakenly given to the wrong patient, it could be the fact that we see this on the news more often that the actual wrong site is actually operated on. This actually happens 10 times a week in our country the wrong body parts operated it on…
N: Ten times a week?
S: Yeah, ten times a week we actually operate on the wrong body parts, site. This could be the wrong finger, this could be the wrong leg, this could be the wrong arm. So this is a very, very difficult, it could be the wrong tooth if it’s an oral surgery.
N: Uh huh.
S: So this things are happening each and every week in our country. It could be that these are even more serious, it could be that there’s an operation that occurs and we leave an object behind in the chest cavity or in the abdominal areas, this is specifically there is a lot of these incidences that occur with obstetric cases in gynecological surgeries where things are left behind basically and then discovered later after an infection is, if the culprit sort of generates interest in looking back at the site and you find that maybe something’s left behind. These are tragic things that are occur and some are in our country are claiming this as never of that, so this should never happen but they’re happening yet single alarming rates based on what we will know is high reliability organizations so this is still too high for the number of cases they get done in our country every year.
N: Now what about these healthcare facilities that cater to the elderly? Are we talking about simply hospitals and surgeries or are we including things that happen in nursing homes, in hospice, things of that nature?
S: So this data, these numbers are really coming from in-patient settings which will be hospital based settings. We really don’t know fully what’s going on outside of the hospital setting. Most of this data is from the inpatient or hospital setting. So places like we would say clinics, your doctor’s office, diagnostic centers, even the skilled nursing and the nursing home arena, we just really don’t know how bad the problem is out there so we’re sure that there almost 70% of care actually occurs outside the hospital. So there is a likelihood that this number could be actually much higher if we include those other settings.
N: So what types of questions should we ask? Will you trust our doctors, our specialist to know what they’re doing? They’ve been to school, they’re making all of the money and there’s supposed to know exactly what they’re doing. What types of questions do we ask to make sure that everybody’s on the same page? And how do we ask those questions to someone that’s so knowledgeable as far as we’re concerned?
S: Well I think what, you hit the nail on the head Neal. Really the first thing is start to ask questions really. And that really how does your hospital … or your nursing facility how do they rate against other facilities in your town, your community, your city? And you can do that very simple you can make you ask that question, there’s research available. One site is very fantastic on the book to help you when start to think about this is hospitalcompare.gov which is from the center for Medicaid, Medicare Services. You can put your zip code in on that website and look at facilities around your radius area and outside and see comparisons of their seeking quality records. So that’s one way you can do some homework. You definitely can start asking questions about safety with your doctor, your nurse, your provider, the healthcare professional which is how can you become more involved on the patient safety team? What can I do to help improve my likelihood that I’m not gonna suffer medical errors? So something is simple as making sure that people are checking your identification bracelet each and every time before and asking you to verbally assert who you are and what your date of birth is, so that you can be solidly recognized that the right patient before you’re ever going to receive a medication. That’s a great question though, is to ask more questions. And those come from becoming more informed about the problem, aware and unlikely to run into some my riskiest situations while I’m in a hospital. And one of those situation that where it’s really risky for you is when you leave a hospital and not fully understand what you’re supposed to do now that you’ve left the hospital and you’ve been discharged and you need to continue to convalesce. And do you have the proper support to help you do that and then to fully understand the instruction that you’ve been given? And also are you able to get the medication that are require for you? And sort of continuing to ask these questions, what would bring me back to the hospital? What sort of things should I be looking for, as a patient or as a family member of the patient that would signal me that maybe I’m getting an infection from the surgery that I just had? And getting that infection dealt with before it become a serious problem and leads to a monumental case of sepsis or some other hospital acquired infection activity. So those are the kinds of things when you say about questions and the book’s full of questions .That’s the key, where you are in any setting that you find yourself from a healthcare perspective, there are lists of questions that you can ask of your healthcare professional to become more informed as a patient.
N: Now where can we get a copy of The Patient Survival Handbook?
S: Well you can go online www.patientsurvivialhandbook.com. You can also just go to Amazon and put in Patient Survival Handbook and it will pop up on Amazon as well. And the electronic version which is awesome because then you can just put it right on your mobile device and have that available to you when you need it. That’s probably the way that the book will used as a tool when you need it, either for yourself or family member. And I think anyone whose what we seen it that moms are generally the leaders on the healthcare team from the home standpoint, they find this to be very valuable resource to them and their families.
N: You’ve been listening to Health Professional Radio, I’m your host Neal Howard. It’s been a pleasure speaking in studio today with Stephen Powell the CEO and president of Synensis and also the co-author of The Patient Survival Handbook. We’ve been here in studio today talking about some of the ways that patients can be more proactive and begin to ask questions, very important questions that can go a long way into keeping yourself safe when you’re under the care of a doctor during hospitalization and after you go home. It’s been great talking with you today Stephen.
S: Thanks Neal. Thanks for the opportunity to talk with you and your audience as well.
N: Thank you so much. Transcript and audio of this program are available at healthprofessionalradio.com.au and also at hpr.com and you can subscribe to our podcast on iTunes.