'I am accountable for those unnecessary deaths'

I just returned from Nashville, TN, where I was invited to appear in a panel discussion with hospital CEOs and board members on the topic, "The anatomy of serious high profile safety events--powerful stories from senior leadership," which was part of a broader session called "Never Events: The Clock is Ticking." I was honored to follow two terrific speakers (see photo above): Paul Wiles, left, CEO of Novant Health in Winston-Salem, NC; and Greg Kutcher, right, CEO of Immanuel St. Joseph's Hospital in Mankato, MN.

Wiles began with a heart-wrenching story about an infant's death from sepsis in his hospital, which was tracked to an MRSA infection. That infection was part of a spread of a bug in his neo-natal intensive care unit that led to the colonization of 18 infants in all, and may have contributed to the death of two others. "This was a direct result of staff not washing their hands appropriately," he said. Since that event, "we have been on a relentless hand hygiene campaign."

The crux of his, and the entire presentation hinged on this comment: "My objective today is to confess," Wiles said. "I am accountable for those unnecessary deaths in the NICU. It is my responsibility to establish a culture of safety. I had inadvertently relinquished those duties" by focusing instead on the traditional set of executive duties (financial, planning, and such).