- Mac's Safety Space - http://blogs.hcpro.com/hospitalsafety -

I might like you better…never say never!

One of the things I frequently share with folks when I’m doing client engagements is that (at least when I, or they, are doing the looking) it is a very good thing to find things: deficiencies, inconsistent practices, etc. My experience has been that the folks in the field will tell you that (insert deficiency/practice here) could “never happen,” and my experience has also been that pretty much everything happens eventually (never being a very, very long time, indeed). You can have the best systems, processes, education, staff that ever has been, but, inevitably, something within those systems, processes, education, staff, will break down or otherwise not quite make the mark. I guess the management of safety and risk in the physical environment boils down to the management of imperfections. Other than certain things in nature (Old Faithful, the sun), the list of things that work perfectly every time is pretty short and I suspect that there’s nothing on the perfect list that is wrought by human hands.

At any rate, I think the underlying subtext is to take full advantage of as many opportunities to poke around as you can make available. The Joint Commission requires surveillance rounds at a set frequency (twice per year in patient areas, at least once everywhere else), but that has to be considered the baseline. The more often you can look, the greater your chances of finding something you’ve not seen before (and presumably had been told could “never happen”). People make mistakes all the time. It is, after all, the nature of humans.