Written by freelance writer and recent college graduate Patrick Jones,
son of pediatric child life specialist Gina Sievert. Patrick is now working
in the healthcare policy industry in Bellevue, Washington.
Frontline healthcare workers are trained, experienced and knowledgeable
individuals who save lives; however, sometimes they make unintentional
errors. These errors can result from a faulty process or an individual
mistake, and it is crucial to figure out why it occurred. The Patient
Safety department takes the time to objectively review an error, analyze
the process and find concrete solutions to enhance safety. “Our
whole job is being collaborative,” says Director of Patient Safety
at Torrance Memorial Bret Barrett. Leading this important process, the
patient safety team frequently collaborates with many departments to make
Torrance Memorial Medical Center the safest hospital possible.
Department Strategy and Mission
The department approaches an issue in two ways. They use Root Cause Analysis
(RCA) and Unit Level Reviews (ULR) to objectively look at a process. RCAs
are larger projects that investigate a potentially flawed process and
find the root cause of the problem. ULRs are like RCAs except on a smaller
scale, focusing on only one or two areas in a single department, explains Barrett.
The mission of patient safety is to keep patients and employees safe, whether
they are receiving treatment or simply clocking-in for the day at work.
For employees, this means providing an environment with a strong hospital
health culture. This culture prevents distractions from work safety and
promotes inclusion and cultural stability in the workplace, allowing employees
to feel comfortable at work. For patients, this culture promotes confidence
and safety while they are in our care.
Career Path to Patient Safety, COVID-19 and Vaccine
Promoting patient safety was not always the career path Barrett had chosen.
His career started in the automotive retail industry working for ten years
at Enterprise Rent-A-Car as the Branch Manager. In 2008, when the recession
hit this industry hard, Barrett decided to pivot to a profession that
would provide more security. Based on his positive personal experiences
with nurses and doctors in the past, Barrett said, “They all seemed
really calm, focused and talented in their jobs, and he greatly respected
this outlook in the healthcare profession.” Going back to school,
he earned his degree at UCLA as a nurse practitioner. After a shoulder
injury prevented Barrett from performing regular nursing functions, he
shifted and soon found a position as the director of patient experience
at UCLA. He was there for three years before getting his current position
as the Director of Patient Safety here at Torrance Memorial in March 2020.
Since he was hired, his job has been affected greatly by COVID-19. During
the pandemic, he has been focused on helping hospital employees come back
to work safely, creating a stable labor pool to allow employees with irregular
hours to work more and create proper face shields for nurses.
Currently, Barrett is overseeing the vaccinators for administration of
the new COVID-19 vaccine. He trains the vaccinators, ensures they properly
consult with their patients and makes sure they are rested and ready for
their extremely important, yet temporary task. “We are here for
every department,” said Barrett.
Interacting With Other Departments and Patients
Patient safety routinely interacts with other departments in the hospital.
Barrett speaks with other directors to learn about any near-misses that
may have occurred and ways to improve safety. Both sides do their best
to look at problems objectively and create a respectful relationship of
understanding dedicated to safety of the patient and employee. Sometimes
Barrett must speak with the family of the patient who suffered from an
incident. Although it can be challenging to remind the family of the event
and obtain information about the incident, it is an essential step in
improving our performance.
Once a month, Patient Safety awards a healthcare worker from any department
with the “Great Catch” award. The award is for the employee
whose near-miss incident was caught and remedied the quickest. This award
gives healthcare workers who experience these alarming moments an opportunity
to feel proud of their trained instincts, abilities and quick-thinking.
Barrett enjoys giving these awards to healthcare workers to instill a
positive feeling for the great work they have done at a time when they
are likely being very hard on themselves. “Yes, this happened to
you, but look what good happened,” said Barrett.
They also collaborate with other hospital’s patient safety departments
to provide aid and share information when seeking solutions to challenging
tasks. These relationships encourage all departments to search for the
best possible resolutions to their problems. Barrett attends a monthly
meeting with Cedars-Sinai patient safety staff to discuss every occurrence
for that month and how to continuously improve new processes put in place.
All this work is done by a team of only three people, including Barrett.
The department subscribes to the Lean methodology in which they work to
cut out waste to be the most efficient financially and operationally and
to improve the approach to patient flow.
National Patient Safety Goals
Recently, the department collaborated with directors and shared the seven
current National Patient Safety Goals and practices. Addressing each one,
the seven goals seem simple like: using medicines safely, using alarms
safely and improving staff communication, etc. By far, the most important
national patient safety goal is to identify patients correctly. “It
is estimated we could eliminate seven of ten events if the hospital identified
all patients correctly,” said Barrett. Although this sounds simplistic
by nature, it is very challenging to develop a process until it becomes
routine. Routine and simple tasks can be overshadowed and forgotten due
to their seemingly small and unimportant nature, however important the
task can truly be. “Once it becomes routine, human nature is to
skip over it periodically or give it less attention. Medication and blood
transfusion mistakes can be traced to incorrect patient identification,”
said Barrett. Patient safety personnel emphasize the great importance
of this step and spends most of their time working on how to properly
and systematically identify patients. “Ironically, the complicated
processes aren’t usually where we see the problems,” said
Barrett. The complex processes are done with much more care due to their
complexities and challenges.
Although Barrett arrived at Torrance Memorial at the start of the pandemic
and has immersed himself in the rapid-paced environment, his favorite
part of the job revolves around problem solving and collaboration. These
are hugely important skills in his position, using RCAs to identify a
problem and working with other patient safety departments to find key
solutions. Barrett and his team do quality work to ensure both the patient
and employee have the safest experience possible at Torrance Memorial.
The Patient Safety Team is a key ingredient to the hospital’s success.