Zero Harm is our Clinical Goal

Attentiveness to Detail, Dedication to a Safety-first Culture, and Accountability to Speak Up: All are Vital

UH Clinical Update | July 2021

By Cliff Megerian, MD, FACS, UH Chief Executive Officer

Our North Star has always been to be the most trusted provider of health care to our community and to our patients. The recent event that occurred during a kidney transplant, and any errors that led to it, is a reminder that all of us, no matter what we do, must be intensely devoted to quality, to designing safe systems, and to coordinating care so we get the details right and patients are provided with the best care.

The event is one that we are not proud of, but we are going to use this No. 1, to learn what went wrong; No. 2, to double down on the notion of the Speak-Up environment, and No. 3, to improve and become more resilient. We want everyone to be part of the solution to get to Zero Harm.

At UH, we acknowledge when mistakes happen, and that they do, but we will use this episode to become the focal point of training and of our efforts to avoid a similar occurrence. To do so, we need everyone to look at how to make care better, and to share with their superiors, or with me, when they have an idea of how to do that.

We also have an opportunity to become more sophisticated and intent on creating and achieving a culture of Zero Harm, to get people to Speak Up, and to let us know about areas in which we can improve. This is the time to get everyone involved and to reaffirm our commitment to Zero Harm.

And there is no question that we must achieve a culture of accountability.

As is the UH way, we are being transparent. We notified the appropriate agencies and the news media about this occurrence, and conveyed that several investigations have ensued.

We will use this as the seminal event to create an enhanced culture, one in which everyone has a hand in seeing what might not be ideal, and then getting their leaders or managers involved, or going even higher up if necessary.

Peter Pronovost, MD, PhD, is our UH Chief Clinical Transformation and Quality Officer, and is leading our effort toward zero harm as our clinical goal. “This initiative began long before the transplant event, and it is heart-warming and hopeful to see how our employees align around this noble purpose,” said Dr. Pronovost. “To learn how we will achieve this, please watch our Zero Harm training video.”

I’ve said this before, but it bears repeating: We will prevent mistakes through attentiveness to detail and dedication to a culture that puts safety first. Each of us, regardless of position, is accountable to Speak Up whenever we see a potential risk to the safety and wellbeing of our patients and each other.

The lives of our patients depend on it.