Patient Safety Awareness Week

This week is National Patient Safety Awareness Week. Across the United States, hospitals, healthcare organizations, and patient advocacy groups have one singular focus: identifying, elevating, addressing, and normalizing patient safety in conversations across the care continuum.

Posted under: Maternal Health, Other, Quality of Care

Last week on LinkedIn, I posted about a young Black woman who died at a hospital shortly after giving birth. She and her boyfriend had been asking for the nurses to call the doctor about the symptoms she was experiencing. Per the report of her boyfriend, the nurses could not call her doctors because “they would get upset.”

Where do I even begin to address the multiple factors that created this tragedy?

This week is National Patient Safety Awareness Week. Across the United States, hospitals, healthcare organizations, and patient advocacy groups have one singular focus: identifying, elevating, addressing, and normalizing patient safety in conversations across the care continuum.

In 2001, the Institute of Medicine (now known as the National Academies of Sciences, Engineering, and Medicine) published Crossing the Quality Chasm: A New Health System for the 21st Century. This landmark document created a conceptual definition of quality, including a focus on care that is:
  • Safe
  • Effective
  • Patient-centered
  • Timely
  • Efficient and
  • Equitable
Let’s return to the scenario described above, and dissect it:

Patient and Boyfriend Asking for Help with Symptoms
April Valentine was a first-time mother and selected her birth hospital as she would “have a Black doctor and a doula to support her” ( According to April’s boyfriend and father of the baby, April could not feel her legs for a few hours. She had an emergency cesarean section and died shortly after the birth of her baby.

Could there have been an outcome that had resulted in a healthy mom and baby? I would like to think that this scenario could have and would have played out under the right circumstances and in the right environment.

But what is the “right environment?” What type of environment would view the patient as “the expert” in their own experience? In their symptoms? Doesn’t the patient know themselves best? In the past few weeks, I have offered multiple examples of patients who expressed concerns about symptoms, only to be dismissed (or a thermostat adjusted so a feverish patient wasn’t so chilled) and suffered harm (or death).

Welcome to High Reliability
Healthcare teams hear the term “high reliability” and immediately think of two things: hard work and more work. And in some cases, they would be right. But “high reliability” is more than a term. It is a state of mind and a state of perpetual readiness. And high-reliability organizations do not occur overnight. These are processes that take years to create, and even longer to sustain. They require the perfect blend of leadership, accountability, and teamwork It is a shared and common purpose that has a few core tenets:
  1. Sensitivity to operations: Awareness of risks and how to mitigate them, including the use of patient outcomes data as a driver of improvement.

  2. Reluctance to simplify: Avoiding overly simplistic reasons for why things fail (communication failure, understaffing, inadequate training). Why did these particular issues occur? What are the reasons behind them? Simply stating “we were understaffed” does not answer the underlying reason(s) for staffing issues.

  3. Preoccupation with failure: Organizations that recognize the importance of addressing near-misses and finding solutions to reduce repetition.

  4. Deference to expertise: Recognition of the importance of the voices of those closest to the patient or to the work, and systems that support “hierarchy” may not have all of the answers to make an informed decision.

  5. Resilience: Teams are in a state of readiness, are prepared and ready to respond to system failures or issues “outside the norm” (
Let’s Return to April’s Story
Imagine for a moment that April had been cared for by a healthcare team that had a foundation of quality and safety as its common purpose and utilized the core elements of a high-reliability organization. Perhaps this is what would have resulted:
  1. April’s care team might have recognized that Black women (even young Black women) are 3-4 times more likely to die in or around childbirth. The team might have considered potential bias and potential forms of institutional racism that may create barriers to safe patient care.

  2. The healthcare team might have deferred to April’s own experience and expertise in her symptoms. She couldn’t feel her legs…what could some of the issues have been? Lack of mobility? Laying in one spot for too long? Something physiologic or worse?

  3. April’s care team might have been more comfortable in calling her providers if there had been a strong, underlying current of psychological safety.
Psychological Safety
Perhaps nothing screams more about this story than the perceived lack of psychological safety within the unit.

“Couldn’t call the doctors because “they might get upset”

Psychological safety has been defined in several ways, but one of the best definitions I have found is an environment that creates the experience of an individual “to be enabled to raise concerns, near misses, and potential errors without fear of negative consequences”. Psychological safety has been discussed in the literature and social media over the last few years, in part due to the challenges of the COVID-19 pandemic. Psychological safety requires crucial conversations about hierarchies within organizations and the importance of team communication. When addressing psychological safety within a healthcare team, it is essential to dissect parts of a unit culture that may need to be addressed more fully. That type I have experienced exceptional leadership dyads within perinatal care. Unfortunately, I have also been witness to those that are a true embodiment of the lack of teamwork and synergy required for patient safety.

Call to Action
I hope a lasting legacy of April’s unfortunate death will shed a light on how important a strong patient safety foundation can be. As we recognize opportunities to address and elevate patient safety, let’s commit to the following actions today:
  1. Recognizing patient care quality must be a daily priority.

  2. Recognizing the patient as an expert in their care.

  3. Recognizing high-reliability opportunities that can promote patient care and multidisciplinary teamwork.

  4. Elevate the concept of psychological safety as a national patient safety goal.
Thank you for everything you do for the care of your teams, patients, families, and communities.

Let’s make every day Patient Safety Awareness Day.

NPIC can assist your team in assessing, measuring, and developing action plans to support psychological safety, and tracking its impact on patient outcomes. Reach out to Elizabeth Rochin to learn more (

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