IHI Patient Congress Takeaways
Reflections from the IHI Patient Safety Congress: Enhancing Healthcare Quality and Safety
This past month, I had the privilege of attending the Institute for Healthcare Improvement’s (IHI) Patient Safety Congress. Over several days, I listened to experts from around the world discuss current healthcare challenges.
For context, the IHI was founded in 1991 as a non-profit organization dedicated to improving healthcare globally. It comprises individual members and organizations that share knowledge and research to enhance healthcare systems. Besides fostering learning and growth, the IHI collaborates with expert organizations to develop its own literature and guidelines.
Transitioning from direct patient care to working at Keriton has highlighted the importance of a robust quality and safety framework. Keriton was founded on the premise of safety by eliminating feeding errors, while also focusing on improving quality outcomes by increasing human milk exposure for vulnerable children. Safety and quality often intersect, a fact that has become evident as I work with new hospitals to implement the Keriton system.
Planning and executing Keriton's deployment involves all parts of a hospital; its success depends on the institution's strong safety and quality culture.
During the transition to our system, we engage with stakeholders at all levels of the hospital hierarchy. A pediatric feeding system may seem like a small piece of technology, but to be effective, it requires the approval and support of:
Hospital-Level Leaders
Department-Level Managers and Directors
Medical Directors and Providers
Supply Chain Managers and Staff
Local IT and EMR Support Teams
Dietitians and Nutrition Services
Lactation Consultants
Nurses
Patient Care Technicians
Unit Secretaries
The teamwork required is immense and only possible when all stakeholders are committed to supporting and improving their culture of safety.
Keriton may be just one spoke in the healthcare system's great wheel, but after listening to the Congress speakers, it's clear that improving patient care falls on everyone whose roles directly or indirectly touch patient care.
In the wake of the RaDonda Vaught case—a nationally covered trial involving criminal charges against a nurse after a deadly medication error—the IHI Congress repeatedly emphasized what constitutes a culture of safety. The consensus among speakers and panelists was that practicing a safe culture means understanding all factors contributing to a safety failure. Blame and punishment alone rarely solve problems or drive change. A genuine culture of safety challenges us to confront hard truths about our processes, formally investigate weaknesses, and commit to real improvements through real action.
Scanning systems to improve feeding safety, especially with human milk, have existed in various forms for years. Yet, potential customers often contact us because they continue to struggle with feeding errors, even with a scanning system in place.
Addressing System Failures in Healthcare: A Call for Improved Safety and Technology
The system is failing nurses, who are already overburdened. It would be easy to blame nurses and end-users for continued errors, and in some cases, gross negligence may play a part. However, as discussed at the IHI Congress, an established pattern of errors likely indicates other factors at work. Approaching improvement from a culture of safety perspective means acknowledging the need for process improvement as well as user compliance.
The hard truth is that healthcare workers are inundated with scanning systems and healthcare technology intended to stop errors. Following the National Academy of Medicine's report To Err is Human, healthcare accepted the role of human error in adverse events and sought improvement. New guidelines and technology flooded hospitals and continue to expand exponentially.
So why, 20 years later, do preventable errors continue to occur?
Emerging research shows that alarm fatigue in healthcare workers is real. Excessive alerts or false alarms contribute to staff ignoring or missing real alarms. In some cases, workarounds become common when technology is perceived as hindering patient care instead of improving it. Staff who lose trust in technology meant to prevent errors stop using it. When remaining safeguards are removed, a risk-laden environment unfolds.
The hard truth is that technology only works as far as the human being on the other end allows it to work.
At Keriton, we strongly believe that safe and effective healthcare technology is always a work-in-progress. Our system was designed to consider the many challenges end-users face when interacting with our platform.
We proudly support a culture of safety, continually seeking feedback from customers/end-users and approaching our design choices with flexibility and a critical eye. As discussed at the IHI Congress, we believe good healthcare technology should strive for high end-user compliance and proactively address areas of concern in real time.
Healthcare technology should never be stagnant. At Keriton, we view our product as an integral member of the healthcare team; as such, we hold ourselves to the same standards of evidence-based practice and quality improvement as our colleagues at the bedside. Hospitals are more than customers; they’re our partners. We strive to serve the individualized needs of institutions and staff to ensure our platform is valued and leads to improved safety and patient outcomes.
On the IHI’s website, they quote an Irish proverb: "When you come upon a wall, throw your hat over it, and then go get your hat." The spirit of that proverb embodies the vision, mission, and values of the IHI and was clearly felt throughout the Patient Congress. They write, "...this one little saying has inspired many big outcomes."
I am proud to work for a company that aims to accomplish big goals and create big outcomes. The team at Keriton knows that these goals can only be achieved by cultivating and maintaining a true culture of safety. It is a core value of our company to never lose sight of our responsibility to the patients we serve and our partners in care who work every day to keep the children they care for safe.
About the Author
Kelly Convery, BSN, RN, IBCLC, is the Clinical Quality Manager for Keriton. She’s a registered nurse with over 15 years of healthcare experience, primarily in the Neonatal Intensive Care Unit. She has been active in quality improvement projects and implementing best practice initiatives throughout her career.