The Healthcare Gauntlet: Being Proactive [Interview][Transcript]

Stephen_Powell_The_Patient_Survival_HandbookGuest: 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, co-author of The Patient Survival Handbook and CEO of Synensis, a healthcare consulting firm, talks about how poor teamwork and communication contribute to medical error.


Health Professional Radio

Neal Howard: Hello and welcome to Health Professional Radio. I’m your host Neal Howard, so glad that you could join us once again today. Our guest in studio today is Mr. Stephen Powell. He is the Chief Executive Officer and President of Synensis, a healthcare consulting firm dedicated to helping hospitals achieve zero preventable harm. And he’s a recognized leader in the development of practices, behaviors, and strategies that improve organizational outcomes. And he is a member of the development team that created the TeamSTEPPS teamwork and communication system for healthcare organizations. He’s also the coauthor of “The Patient Survival Handbook.” And he’s here today to talk with us about taking charge of your healthcare, being proactive and how a lack of communication among our healthcare professionals can sometimes lead to sometimes fatal medical errors. How are you doing today Stephen?

Stephen Powell: I’m doing great Neal. Thanks for having me today on the show.

N: Thank you. I was looking at the information when I came across your name and it was saying that medical errors is the third leading cause of death in the United States. We’re not talking about a single disease or some type of illness, we’re talking about mistakes of the third leading killer of those of us in the United States?

S: Yeah exactly Neal, that’s a big number. And I think it’s really hard from an awareness standpoint it doesn’t get the attention that number one heart disease, number two cancer, yes and this thinking. So it’s not in the top of everybody’s tip of their tongue and they’re not thinking about it unlike other diseases. We’re thinking about what can we do to you know make ourselves healthier to prevent you know becoming ill due to one of those maybe disease factor, that like –exercise or diet, that might improvement an outcome for sort something we can do to preventive wise improve our health. I think really if we believe the numbers which there’s been a significant amount of research done in this area patients seeking quality now. And also we’re learning more as we develop other ways to uncover these errors, which generally been buried inside of our healthcare system and not as prevalent. But also these occurs to one patient at a time and in various ways in different outcomes. But these are things that we would recognize probably when we think about when I say some of the problems that causes, things like hospital acquired infections or suffering acquired while you’re in the healthcare facility as a patient because of maybe a medication or false assessment that wasn’t completed or developing a pressure ulcer in a nursing facility. We can all probably think of either ourselves or a relative or a close friend that may have had something like that that happened to them. This are preventable in the most part we’ve found that these are preventable medical errors and these make up some of those almost 400,000 lives that are impacted by medical errors each year in our country alone.

N: Now hospitals have been around for quite a long time. Mistakes have been made for quite a long time. As scientists, don’t doctors learn from mistakes that are made putting new discoveries into practice on a practical level to prevent these preventable mistakes? And with the technology that we have, how are so many of us still dying from these preventable mistakes? Not mistakes that were under no one’s control, something exploded and everybody in the OR died. But these are preventable mistakes, how are they still occurring?

S: Well, I think we have made a lot of strides in our technology, our equipment, some of our practices. But you know I think some of the challenges Neal are kind of some simple things that are more behavior based and when we look at the serious safety events like these deaths or serious injuries, some people in the industry call the signal, what we find is from the data that the top four leading causes of these aren’t really related to kind of a medical technology. They’re related to that number one category of root cause is human factors and I’ll go into what that means, what human factors are. But they’re really the fact that we are human and we make mistakes, so we can talk more about that. Next is communication which I know we’ll get a chance to talk more about that, leadership and then finally this area of assessment. So actually diagnosing and having this what we’ll call “situation awareness” have a full understanding of the patient’s conditions and then understand how best to treat their conditions that the patient presents. But sometimes that’s also related to some of that lack of good information that’s not available to practice. Sometimes that’s preventable sometimes it’s not, in the case of an emergency room doc that may not be easy in any case to get all the information of a patient that presents after say an auto mobile accident in the ER. We don’t have all the information. But the pillars of the four top causes, they’re not generally related to what we would normally know as our professional technical skills as doctors and nurses. Like our ability to technically do a procedure or to deliver the right IV placement or central line placement or whatever therapy we’re receiving. It’s more about our non-technical skills, our ability to be good teams and communicate.

N: Now let’s talk briefly about your company Synensis. You’re the President and CEO of Synensis and while we’re on the topic of preventable zero errors, what type of training information or either supplying equipment do you supply to healthcare facilities in their efforts to attain zero preventable errors?

S: Well what we try to do or we have been doing really for the last over a decade now with over now 500 organizations we work across in a large spectrum in over 70 countries, because honestly Neal this problem and challenge is it doesn’t know any borders, right? Because humans are humans no matter where we go on the planet. And so what we’re trying to help organizations do is number 1: realize that human error is inevitable. We cannot discipline or punish our way out of this problem. So what instead we’re doing in helping organizations do is helping them to do, number 1 design better systems of care with the human factors in mind. And there’s a very comprehensive body of evidence on how to do that. And other industries have actually embraced this more light sprint than healthcare imagine that. Other high risk industries like aviation, nuclear power, and the military for instance. And so that’s the one part, yeah and then I think second with that I’ll tell you Neal, one of the other key part of that is to achieve better outcomes really which is to prevent this preventable errors from occurring, is also helping organizations understand how to help their healthcare professionals, staff, leaders make better choices each and every day as it relates to the continuum of care. So along with those safer systems and better designed system is also making better choices. Those choices that are directed more at really focused on the patient and their experience of care more so than our own personal choices if you will, that make things better for us but not necessarily better for the patients.

N: You’ve been listening to Health Professional Radio, I’m your host Neal Howard. In studio today we’ve been talking with Mr. Stephen Powell. He’s 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 to drive results, develop high reliability teams, accelerate quality improvement and reduce medical errors. And he’s been involved in human factors education and team work training in the United States Navy, the Commercial Airline Industry and the Healthcare Industry for over 25 years. And he’s been with us today talking about some of the reasons that preventable medical errors still occur and some of the ways that his company is helping to stem the tide of convertible medical errors that often end in fatal results. It’s been great talking with you today Stephen.

S: Thank you Neal. I really appreciate the opportunity to talk and speak with your audience as well.

N: Thank you. Transcript and audio of this program are available at and also at and you can subscribe to our podcast on iTunes.

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