Watch the full lecture by Dr. Peter Pronovost, the Johns Hopkins Medicine’s senior vice president for patient safety and quality, on the science of improving patient safety.

The quality of the video may not be that good but it is a great lecture.

As you watch this video lecture, note some highlights from this lecture:

1. Dr. Pronovost mentioned at the beginning of his lecture that one of the conundrum in medicine is the belief of heroism.  Although heroism has led us to a lot of medical discoveries but it can also hinder us from designing a safe system because it leads us to believe that we can be perfect.  Rather, we need to admit that we are fallible.

Reflection: how important is the virtue of humility in promoting a safe clinical culture in your hospital/clinic?

2. The four basic points of the science of patient safety mentioned by Dr. Pronovost are (paraphrased):

• We need change our perception from the it is our personal performance to the system that is responsible to drive the results we want
• We need to create independent checks to ensure safe design, e.g., standardized checklist, when things go wrong, have a way to learn from them
• We need to create a safe design for our system (and this isn't just applied to our personal work, but to the our entire team)
• We need to learn to speak up and listen to our team members

3. Three principles for safe design are

• Standardization of our work processes/steps (and eliminate unnecessary steps)
• Creating independent checks
• Learning from errors

4. How do we learn from our errors (4 questions to ask):

• Ask what happened?
• Why it happened?
• What could you have done to reduce the risk?
• How could you be sure that it will work?

5. Dr. Pronovost mentioned that most of the failure events are due to communication problems (minute 15:00).
He then proceeded to present a basic communication model at minute 21:06.

Reflection: what could go wrong along this communication loop (from the sender, the message sent, the message received, the receiver, the setting/environment perspectives)?