A Blue Christmas

The message inside the card reads, "Wishing you Christmas peace."

Some things just don't make sense. 

Elvis-as-messiah is one of them. And why a pharmacist will spend Christmas behind bars this year for an on-the-job error is another.

You can read more about Eric Cropp and the circumstances behind the tragic death of a toddler here.

Eric's address in the Cuyahoga County, Ohio jail appears at the bottom of the linked article. I'll be sending him one of the Elvis Christmas cards. There are 17 others in the box. I'll be happy to send one on your behalf, too.

These are a few of my favorite things.....

That's what Julie Andrews sang in the Sound of Music.

But I found them set to a different tune in a patient safety video created by nurse leaders who are DNP candidates. Thanks to Marie Duffy, Nancy Ramos, Cynthia Robotti, Rosita Rodriguez, and Sheryl Slonim for producing this excellent resource!

I am thankful!

People who check in at Florence dot com come from all over the world, united by a desire to see better, safer healthcare systems emerge. I'm happy my efforts are contributing to hard work being done by so many others and thought it would be interesting to share where visits to Florence dot com came from last month.  (The darker the green, the more visits from that region.)

In this season of thanksgiving, I want to say how grateful I am for the opportunity to share reflections and pass along resources I value with so many of you.

This week, I heard a physician leader in a large multi-system healthcare organization talk about progress her organization has made in patient safety. The gains were substantial, and hard won, coming not from gorging on cheap Happy Meals, but from putting safety and quality at the center of the table where bright, powerful, and connected people in the organization regularly convene. These people not only plan the meal, they're accountable for what's served.

Patient safety, a component of quality healthcare, isn't the same as quality. People struggle to understand their relationship, especially in complex and evolving arenas like healthcare. Safety doesn't prove which chemotherapy regime is the most efficacious. It's what allows the one selected to be delivered as intended.

Safety may not reveal God's perfect truth. But, done well, safety is what allows humans to facilitate the activities--some miraculous, some mundane--needed to heal. If therapy fails because the chemotherapy regime selected isn't the best match for a person's genotype or stage of cancer, more work on the quality side of performance improvement is needed. But if a person dies from an accidental chemotherapy overdose or doesn't receive the curative benefits because of less obvious dosing errors, there's work to be done on the safety side.

I learn the most when people who are well into the safety journey talk about where they're stumbling. The physician who shared inspirational data about the reduction of serious, preventable safety events in her organization shook her head when asked about the barriers that prevent further gains. "It's hard," she said, "to make humans perform as flawlessly as the healthcare system needs them to."

This means that even in healthcare organizations where demonstrable gains in patient safety have been made, there's still plenty of work to be done. Improving system design and actively shaping the choices made by people who use the system is how David Marx, a systems engineer, attorney, and the author of the Just CultureTM algorithm, describes the work leaders undertake when they gather to create and sustain a culture of safety.

This year, one of my best reads was Marx' book, Whack-a-Mole: The Price We Pay for Expecting Perfection. It's a resource I'm thankful to have and one I hope you'll find helpful in your journey toward safest care, no matter where you are (in the world or on your journey).

Oh, and thanks for checking in today and on so many other days this year. Come back soon!