Elevating Patient Safety

patient safetySince publication of the Institute of Health (IOM) report entitled “To Err is Human,” our healthcare system generally, and hospitals specifically, have tried to create, develop and nurture a culture of patient safety. The IOM reported almost 100,000 Americans lose their life each year due to preventable medical errors. In fact, according to the IOM, “More people die in a given year as a result of medical errors than from motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516).”

Something must be done to reduce or eliminate medical errors that could have been prevented.

The IOM report further states, “This report describes a serious concern in healthcare that, if discussed at all, is discussed only behind closed doors. As health care and the system that delivers it become more complex, the opportunities for errors abound. Correcting this will require a concerted effort by the professions, health care organizations, purchasers, consumers, regulators and policy-makers. Traditional clinical boundaries and a culture of blame must be broken down.”

However, a culture of patient safety is on a collision course with that culture of blame. Unfortunately, a culture of blame in healthcare is reinforced by our current medical malpractice litigation system. It is a system based on a “shame and blame” mentality.

When physicians, nurses and other clinicians labor under a system where they are shamed and blamed for medical errors, those healthcare professionals are unlikely to come forward and admit mistakes.

Because of the threat of lawsuits, healthcare professionals typically try to conceal medical errors. Once again, that is not an environment that will create a culture of patient safety. Rather than have a positive impact, our medical litigation system actually hurts patients.

The recent tragedy in San Francisco involving the Asiana Boeing 777 aircraft demonstrates the difference between the commercial aviation system and the healthcare system. Within hours of the accident, the National Transportation Safety Board (NTSB) and the Federal Aviation Administration (FAA) interviewed the flight crew and survivors. Each will issue a report with specific recommendations on how prevent a similar accident from happening again.

In healthcare, however, we blame physicians, nurses, pharmacists and other professionals. We don’t interview the healthcare professionals after an error to devise processes and systems to prevent future medical errors. We simply don’t treat medical errors like the NTSB and FAA treat aviation accidents. We almost pretend they never happened.

Due to fear of lawsuits, the medical litigation system also promotes a culture of defensive medicine or when physicians order unnecessary tests, medications and procedures such as x-rays and CT scans that do not aid in the diagnosis or treatment of the patient. They are solely ordered to protect the physician from a medical malpractice claim. In Georgia alone, defensive medicine costs employers, health plans and patients up $14 billion annually.

Additionally, in a recent survey, more than 80 percent of Georgia physicians say they practice defensive medicine. And more than 95 percent think that defensive medicine has a negative impact of patient care.

If the current litigation system is broken to the point that it brings on unintended consequences including more uncorrected medical errors, higher healthcare costs and escalating malpractice premiums, maybe it is time to rethink the way our state’s medical litigation system current system operates.

One comment Add your comment

Nancy Curdy

July 11th, 2013
9:09 am

Thank you for continuing to shine a light on the work that is so important in healthcare, for our patients. I need to revise one of your comments, however.- ‘In healthcare, however, we blame physicians, nurses, pharmacists and other professionals. We don’t interview the healthcare professionals after an error to devise processes and systems to prevent future medical errors’
Healthcare actually has a very robust system of investigating events (both errors and near misses) in healthcare systems, called Root Cause Analysis or Intense Analysis. We also have a robust system of assessing a change in process, for instance, in advance of implementation called a Prospective Review or Failure Modes and Effects analysis. We look for all of the areas where failure can/may occur and put processes in place to help mitigage those failures. We’re certainly not always perfect but its important to note that US Healthcare, as well as, worldwide, is working stringently to become safer and more highly reliable. We study the High Reliability Organizations, such as the airline industry and the nuclear industry, in order to learn how to translate that to Healthcare. I wanted to make it clear that we are not standing still. There is nothing more important than the safety of our patients transitioning through our systems from the hospital to home, to the outpatient setting, etc. In fact, its safe to say we are pre-occupied with failure with the intent to prevent it and if that doesn’t happen, learn from it.