Archive ORX Session Previews 2018

The Nurse Manager's Role in Patient Safety

It's your responsibility to create an environment that ensures staff remain vigilant about protecting those in their care.

William Duffy

William Duffy, RN, MJ, CNOR, FAAN


William Duffy, RN
William Duffy, RN, MJ, CNOR, FAAN Loyola University's Marcella Niehoff School of Nursing Chicago, Ill.

Every healthcare worker fears "alarm fatigue," the potentially deadly hazard where workers tune out alerts from monitors, ventilators and other machines due to their ubiquity. Could the same type of phenomenon be responsible for the overall epidemic of patient safety errors?

Bill Duffy, RN, MJ, CNOR, FAAN, thinks so. And we should listen. The former VP of perioperative services for Evanston Hospital has serious patient-safety cred. As AORN president in 2004-2005, he led the effort to develop and promote the toolkit that ultimately morphed into the WHO safety checklist that all surgical facilities use (or should use) today.

Patient safety errors may sometimes occur because of incompetence, says Mr. Duffy, but a much more dangerous source of errors is desensitization and inattention. Constant exposure to life-and-death situations day after day after day causes nurses to "normalize the danger," he says. A combination of complacency and time pressures results in errors.

To understand how it works, consider "overlearned" skills like driving, says Mr. Duffy. "When my daughter was first learning how, she was extremely nervous and had the white knuckles to show for it. By the time she turned 22, she was flying down (Chicago's) Kennedy Expressway in heavy traffic, steering with her knees. She believed she had mastered driving and no longer feared this 2,000-lb. weapon."

During Mr. Duffy's entertaining multimedia exploration of the role OR leaders play in ensuring a safe environment for patients and staff, you'll see memorable video clips of real and fictional disasters and near disasters that occurred not because of incompetence, but because of inattention. "I believe we remember things we see much more vividly than things we hear," he says.

Mr. Duffy says he learned that he could hurt patients in his first year in practice. "A patient had been administered a medication, and it had been discontinued. However, when I visited the bedside, there was still another dose in the bin. I glanced at the record but didn't notice the discontinuation and went ahead and administered the extra dose." The patient was fine, but Mr. Duffy never forgot that the outcome could have been different. "Every day, before I entered the OR, I prayed that I wouldn't hurt a patient that day."

He advises OR staff to heed the warning in the Allstate commercials: "Mayhem can happen at any time." OSM

  • Past president of the Association of periOperative Registered Nurses (AORN), where he led the association's effort to eliminate wrong-site surgery.
  • Director of the Health Systems Management MSN program at Loyola University's Marcella Niehoff School of Nursing.
  • A renowned national and international lecturer, and author of numerous articles and chapters about nursing leadership and risk management.
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