Recently I witnessed firsthand the kind of leadership that saves lives. It was, perhaps, a simple decision — one that might have gone unnoticed. But it reflects the kind of leadership we need to create a true culture of safety in our nation’s hospitals.
I am on the Quality Committee of the Board of CHE Trinity Health, the $13 billion Catholic health system with 82 hospitals in 20 states, as well as many hospice and continuing care programs.
We were reviewing a case before the committee. A patient in the operating room at one hospital improperly received nitrous oxide — used as an anesthetic and lethal in heavy doses — instead of oxygen. The mistake was noticed quickly and the patient was not harmed.
Nonetheless, it was a close call that we needed to investigate. We had many questions. We learned that a warming blanket covered the two tanks, oxygen and nitrous oxide, obscuring their different colors. But we also knew the oxygen tubing should not have been able to connect to the nitrous oxide tank. This safety feature is designed to compensate for the inevitable human error.
So what went wrong? The safety valve, we learned, is attached to the tanks after the tanks are delivered to hospitals. A member of the hospital staff attaches the correct safety valve to the correct tank. But after hundreds and hundreds of attachments throughout the years someone, one time, attached the oxygen safety valve to the nitrous oxide tank.
Richard J. Gilfillan, MD, President and Chief Executive Officer of Trinity CHE, listened as people on the committee discussed ways to prevent another occurrence. Should a second hospital staff member review the installation of the safety valve? Could some other round of checks and double checks be required? We learned that the vendor of the nitrous oxide tanks could not deliver the tanks with the safety valves already installed.
Then Dr. Gilfillan spoke.
“Get another vendor,” he said.
It was a simple statement. Dr. Gilfillan made this clear: No oxygen or nitrous oxide tanks would enter any Trinity CHE hospital without a safety valve already attached. Dr. Gilfillan did not ask about the cost or about hospital or vendor politics. He did not entertain other options.
He made a simple declaration that patient safety comes first.
We know that to err is human. Dr. Gilfillan’s decision was supported by Dr. P. Terrence O’Rourke, CHE Trinity Health’s EVP of Clinical Transformation. They both know that we cannot completely prevent humans from making errors. Instead we must create fail-safe systems that will prevent the human error from becoming a human tragedy.
The last thing hospital officials ever want to talk publicly about is error. But Dr. Gilfillan has allowed me to write about this experience because he knows that we must talk about safety. We need good systems, technological advances, and education to reduce medical errors.
But the most critical component is courage and leadership.