Learning Lab: Navigating Risk in Healthcare Quality and Safety-Learning Lab: Navigating Risk in Healthcare Quality and Safety

Video Transcription

Video Summary

The session introduces part one of a three-part patient safety learning lab focused on “seeing risk before harm” through proactive safety practices. Hosted by Sherry Hobbs Messick and Maggie Kane, the presentation emphasizes shifting healthcare from reactive responses to early risk identification and prevention.<br /><br />The speakers explain that harm prevention is more effective and less costly than recovery after an event. They highlight the human, financial, operational, and reputational impacts of delayed detection, using the Duke hydraulic fluid incident as a cautionary example of how ignored warning signs can lead to patient harm.<br /><br />A major focus is proactive risk assessment, especially Failure Modes and Effects Analysis (FMEA). The presenters describe how teams can map processes, identify failure modes, analyze causes, score severity/occurrence/detection, and prioritize the highest risks. They use wrong-site surgery prevention as an example and note that FMEA is especially useful for new services, technology changes, transitions of care, infection prevention, medication risks, and repeated near misses.<br /><br />They also discuss how to build early warning systems using multiple signals: event reports, rounding insights, culture surveys, staffing strain, operational variation, and patient feedback. The goal is to collect signals in one place, look for patterns, and act on the few risks that matter most.<br /><br />Finally, the session explores drift and normalization of deviance—gradual shifts away from safe standards that become accepted over time. Leaders are encouraged to observe work as done, ask what has become “normal” that would surprise them, strengthen psychological safety, and close feedback loops quickly.

Keywords

patient safety

risk prevention

proactive safety

Failure Modes and Effects Analysis

FMEA

early warning systems

wrong-site surgery

normalization of deviance

psychological safety

healthcare risk assessment