Author

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President & CEO, University Health Network

Dr. Peter Pisters is an internationally known health system leader and academic surgeon. He began his tenure as President & CEO of UHN in January, 2015, and is currently a Professor of Surgery at the University of Toronto. Prior to joining UHN, he spent 20 years at The University of Texas MD Anderson Cancer Center as a tenured faculty member in a number of clinical, administrative, and leadership positions. Dr. Pisters served as a Vice-President with leadership over MD Anderson’s regional expansion strategy and multi-site metropolitan Houston operations. As President & CEO, Dr. Pisters is taking UHN on a journey of renewal, aimed at strengthening the organization for patients, staff, physicians and volunteers, through the implementation of key areas of focus. This renewal is helping build the foundation for UHN’s future success.

See Something, Say Something – Canadian Patient Safety Week

This past month the spotlight has truly been on safety – last week was Canadian Patient Safety Week, and here at UHN we made October Caring Safely month. I am so encouraged to hear the voices speaking out about safety collectively getting louder.

As future health care professionals, the topic of safety is critical for Michener students. The reason so many of us enter this field is to help and to heal – it’s a unique thing that binds us together. No matter what your role is on the health care team, caring for patients requires a keen attention to safety.

Despite the best of intentions, preventable harm does happen, and more often than many realize. Unfortunately there isn’t reliable data in Canada, so we must extrapolate from the US – by our estimates more than 30,000 Canadians die each year as a result of preventable harm. Even as an experienced surgeon, I had my own encounter with an unintended medical error. I shared that story here. This experience changed me as a health care professional and as a result I am relentlessly focused on transforming the culture of safety in the health care.

It’s incredibly important for me to change and reframe the organization, which is why I see myself as the Chief Safety Officer at UHN. However, I wasn’t always so comfortable speaking up for safety.

When I was an intern, I was assisting in an operation to remove a gall bladder, which was being performed by the attending surgeon and the Chief Resident. The attending surgeon was an imposing figure, who was viewed as mean and judgmental by the staff. He was rude, disrespectful and feared by the nurses because of his temper.

During the operation there was bleeding and a tubular structure was divided. As the attending surgeon described what he was doing, he told us this tubular structure was the cystic duct; cutting this duct is a standard part of gall bladder removal surgery. Both the Chief Resident and I were concerned that this was not the cystic duct, but in fact the main duct leading out of the liver – the common bile duct. However, neither one of us spoke up during the operation, we were too afraid to convey our concerns that the surgeon was making a mistake.

In the locker room after the operation the Chief Resident looked at me and said, “Did you see what just happened? He cut the common bile duct. We will be operating again in three days to fix this problem.” 48 hours later the patient was deathly ill and went back to the operating room, just as the Chief Resident had predicted. At that moment, I fully grasped how an ingrained culture of fear – a culture that suppresses reporting – leads to major gaps in safe patient care.

Health care can be a very hierarchical industry. I believe it’s so important to break down those barriers. We are all here to serve our patients and it’s our collective responsibility to stand up for them. So I urge you – if you see something, say something. Whether it’s as a student, a new professional or a seasoned industry leader, we all have a responsibility to care safely for our patients, and one another.

I am so proud of the work we are doing at UHN, in partnership with the Hospital for Sick Children, on our safety transformation, Caring Safely. The purpose of this transformation is for everyone at UHN – clinical and non-clinical staff, researchers, and students – to be committed to creating a safe environment for our staff and patients. Through hard work, reliability and resilience, Caring Safely will help us with three important “E’s”:

  • Eliminate harm;
  • Elevate defenses; and
  • Ensure rescue.

The Institute of Medicine once noted “errors… are costly in terms of loss of trust in the health care system by patients and diminished satisfaction by both patients and health professionals.” By decreasing incidents of preventable harm and increasing a focus on patient safety we can create a healthier and smarter environment for everyone that comes through our doors.

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