JOINT BASE LEWIS-MCCHORD, Wash. - A patient undergoes intraocular surgery successfully; however, when the patient wakes, doctors explain that the wrong type of lens has been implanted and that additional anesthesia and surgery is now required. A mistake that could have easily been prevented.
Lt. Gen. Patricia D. Horoho, the Army Surgeon General and commanding general of U.S. Army Medical Command, shared this example of preventable harm with senior medical leaders during the Western Regional Medical Command High Reliability Organization Summit at Joint Base Lewis-McChord March 4.
The summit provided a forum for the medical community to discuss the challenges and strategies of becoming an HRO, which is an organization that is consistently successful in its goal of achieving zero preventable harm, despite operating in an environment where human error is possible and accidents can occur due to risk factors and complexity.
"The concept of HRO is a journey of instilling safety in every aspect of the delivery of care and readiness," said Horoho, who is leading the Army Medicine initiative of zero preventable harm by working to build a barrier between human errors and non-preventable harm.
Medical leaders and professionals in organizations that span five continents are striving to meet the top imperatives to becoming an HRO - leadership commitment, robust performance improvement and creating a culture of safety.
"Whether you are the most junior person in the room or the most senior, you are empowered to stop what's going on and bring forward something that's potentially harmful," said Maj. Gen. Thomas R. Tempel, Jr., chief, U.S. Army Dental Corps and acting commanding general, WRMC.
The summit included "Collective Mindfulness" portion that presented an opportunity for the leaders to discuss the principles of an HRO. The meetings were focused on how to implement a reluctance to simplify, a sensitivity to operations, a deference to expertise, a commitment to resilience and proactivity in preventing errors into the Army medical community.
"In the medical world, you have a lot of adversities, you have a lot issues that you are faced with," said Command Sgt. Maj. Marshall L. Huffman, the WRMC Command Sgt. Maj. "You have to be able to bounce back from those adversities. Being resilient is something that we do on a daily basis."
Whether an error occurs at the lowest or highest level, the need for self-reporting, as well as a change in culture was the consensus at the conference.
"We are going to have errors because we're all human and humans make mistakes," said Horoho. "What we don't want to have is an error that leads to preventable harm."
Throughout the summit, the comparison was drawn between the high risk and complexity of the U.S. airline industry and Army Medicine. There has not been a major U.S. airline accident since 2001 because of the hardened safety processes and improved systems, and Horoho said that while Army Medicine cannot realistically erase preventable harm, the goal of zero preventable harm will positively impact Army Medicine.
"Safety is the primary mission of what we do," said Horoho. "Safety needs to be pervasive in every aspect of our leadership and every aspect of our health care mission."
Horoho closed by requesting that command teams identify their unit processes and systems where errors are likely to occur, work on solutions for correcting those errors and ensure the knowledge is shared across their organization.
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