The Time I Made a Mistake...

Every now and then, something happens that creates a vivid memory. The kind you can replay years later, whether you want to or not. Sometimes those moments are joyful. Sometimes they are painful. For me, one of those memories goes back to early in my career as a practicing hospitalist, when I made a medical mistake that caused harm to a patient.

At that point, in my own mind, I was fast, efficient, confident, smart, and, frankly, a pretty awesome hospitalist. I did say in my own mind! But in my haste, I missed something important. And when I realized that my mistake had hurt my patient, I felt terrible. Remorse. Shame. Guilt. It was humbling, deeply painful, and one of the most important learning moments of my career.

That experience is a big part of why I care so deeply about zero preventable harm.

For me, zero harm is not a catchy phrase. It is a mindset. It is a standard. It is a promise we make to our patients, their families, and each other. And while we may never eliminate every risk in healthcare, we should be relentless about reducing preventable harm wherever and however we can.

So who owns this work? Just the Quality and Safety team? Nope!

Safety belongs to every single one of us. Of course, it’s easy to see how it relates to our physicians, nurses, pharmacists, and other clinical team members on the front lines of patient care. But if you work in environmental services and help keep spaces clean, you are preventing harm. If you work in facilities and fix something before someone trips over it, you are preventing harm. If you are a scheduler who gives a patient access to an appointment they need, you are preventing harm.  

Even those who never step into a patient room still shape the safety of the care we provide... whether you work in IT, billing, security, compliance...you see where I’m going with this... No one gets to say, “Well, that’s not really my department.” At GBMC HealthCare, it is everybody’s department.

That is also why, in our employee spotlight features, you will keep seeing a question about zero harm. That is not accidental. We ask it on purpose. I want every employee, regardless of title or role, to think about how they contribute to safer care. Because they do.

This week, during Patient Safety Awareness Week, our Quality and Safety team, led by Sam Crandall, is hosting activities designed to educate, engage, and inspire our teams around the role we all play in safety. I love this year’s theme: Team Up for Patient Safety. Because that is exactly right. Safety is a team sport.

One of the more creative events is the Room of Horrors, where participants try to spot safety risks in a simulated environment. It is engaging, memorable, and a little bit like the escape room craze... except instead of escaping, the goal is to notice what could cause harm before it actually does. We will also have a Hall of Fame, showcasing patient safety work from across the organization. And importantly, this is not just happening in the hospital. Our offsite teams are part of this too, with virtual opportunities, including their own virtual Room of Horrors experience.

Patient safety is not one week of activities. It is everyday work. Careful work. Teamwork. And some of the most important work we do.

So as we mark Patient Safety Awareness Week, I hope each of us takes a moment to ask: 
How do I help prevent harm? 

Because zero harm belongs to all of us. 

Employee Spotlight

Kayla Brown, BSN, RN

RN 3 - Unit 58

GBMC Hospital

How long have you been at GBMC HealthCare?

This year will mark 8 years at GBMC!

What is one key way you support a zero harm/safety culture?

I believe I try to support a zero harm/ safety culture by focusing on teamwork and promoting a supportive environment, ensuring that everyone feels comfortable speaking up when something doesn't seem right.

What is the most rewarding part of your job?

The most rewarding part of my job is being able to make a difference in patients' lives, especially at their most vulnerable. Small acts of reassurance and some advocacy can bring comfort and safety when someone needs it the most!

What's your favorite hobby?

I've recently taken up running as a hobby and hope to become involved in some races starting later this year!