OP-ED

The Patient Safety Movement Turns Ten

On December 1, 1999, the Institute of Medicine released a report entitled To Err is Human: Building a Safer Health System. Although its authors hoped to spark a national movement, they had little cause for optimism. After all, early efforts by advocates like Berwick and Leape and organizations like the National Patient Safety Foundation had barely moved the needle of public and professional attention.

The IOM Report succeeded beyond its framers’ wildest dreams, and the movement they spawned turns ten today. Please indulge me while I spend a nostalgic moment recalling the remarkable spin that launched the patient safety field. I’ll then segue to a summary of my assessment of what we’ve accomplished over the past decade (I outline this more fully in an article in this week’s web version of Health Affairs, which I hope you’ll take a look at).

In Internal Bleeding, after describing the history of the IOM (founded in 1970 as the National Academy of Science’s think tank for healthcare issues) and the fact that the venerable organization was not exactly known for its eye-popping PR, Kaveh Shojania and I wrote:

So one could not help but be taken aback by the screaming headlines that leapt off the book jacket of the [IOM Report]. One part Constitution Avenue to three parts Madison Avenue, its tone instantly caught the attention of the general populace and the media. Just consider the breathless prose of the book jacket, more like the trailer for a Hollywood blockbuster than the synopsis of an academic report:

Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That’s more than die from motor vehicle accidents, breast cancer, or AIDS—three causes that receive far more public attention…. This volume reveals the often-startling truth of medical error and the disparity between the incidence of error and public perception of it…

As if that wasn’t enough pizazz, the authors converted the staggeringly large but potentially bloodless “44,000-98,000 deaths per year” figure into the now-famous “Jumbo Jet Units” – making the point that the number of deaths from medical mistakes was the equivalent of a large plane crashing every day.

Although some have critiqued the “crash-a-day” spin as hyperbolic, I continue to believe it was masterful. Something was necessary to shake us out of our collective inattention, and it took the Jumbo Jet analogy to do it. (And just consider what our response would be if, in fact, a commercial airliner crashed for “just” two or three days in a row!) The IOM Report received saturation media coverage for several days, after which more than 50% of Americans surveyed were familiar with the epidemic of medical errors. In one bold stroke, medical mistakes joined airline and food safety (and, two years later, terrorism) as enduring sources of angst in the American zeitgeist.

While there are many metrics of the IOM Report’s impact, my favorite is this: even today, one can say “The IOM Report” and most folks will understand the reference to To Err is Human. This, despite the fact that the IOM has published 526 reports since To Err is Human. Want more: a Google search on “Institute of Medicine Report” pulls up the IOM’s website as the first hit; To Err is the second.

That’s all well and good, but what have we actually accomplished? In today’s Health Affairs article, I present my view of the progress we’ve made in the patient safety field’s first decade. I give us an overall grade of B-, a slight increase from the C+ I awarded 5 years ago in a similar Health Affairs paper.

In writing today’s article, I was struck by the emergence of state reporting systems, centered around the National Quality Forum’s list of “never events,” as the key maneuver that got safety reporting off the ground, and the increased safety activity within hospitals (many of which now have fairly effective patient safety enterprises) and national organizations (such as the NQF and AHRQ). On the other hand, it is remarkable how little progress we’ve made in IT (particularly when you contrast it with the breathtaking progress we’ve made in IT in virtually every other part of our personal and professional lives), and how we’re just beginning to grapple with balancing “no blame” and accountability. And, as I feared, regulators and accreditors are facing increasing challenges, as the low-hanging fruit (such as abolishing high-risk abbreviations) has been picked, leaving them struggling to improve performance in highly complex, nuanced areas like safety culture, medication reconciliation, and addressing problems caused by disruptive caregivers.

Many people will look at the past 10 years and wonder whether we’ve accomplished much of anything. I sympathize with this concern, one that’s partly driven by our maddeningly limited ability to measure progress in safety. Yet as I wander around my own medical center, signs of progress are unmistakable. Our safety enterprise is much more vigorous than it was five years ago (it was nonexistent 10 years ago). Despite some major IT snafus, we are using an electronic health record, and it is a far better way of communicating information than via snippets of chicken scratch penned on dead trees. During a weekly two-hour meeting, we analyze serious errors and review progress in fixing the unsafe conditions we uncover. Our residents and students are (mostly enthusiastically) participating in new safety and quality curricula. We are measuring safety outcomes such as healthcare-associated infections and reporting these results regularly at the highest levels of the organization. All good stuff.

Yes, there is much more for us to do. Patients everywhere are still harmed by preventable infections, falls, communication glitches, wrong-site surgery, medication mix-ups, and more.

But that’s for tomorrow. Today, let’s also take a moment to celebrate all the good work over the past ten years. In fact, had you asked me on December 1, 1999 how much progress would be possible in the next decade, my guess would have markedly underestimated what we actually have accomplished. As I visit hospitals and healthcare systems around the country, I have been struck by the passion and energy doctors, nurses, pharmacists, and administrators have put into preventing patient harm – driven as much by their moral compass as by the increasingly robust business case for safety.

So, even as we vow to redouble our efforts in the second decade of the patient safety movement (and we must), we should take some pride in the work of the first, work that has unquestionably saved many thousands of lives.

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Cole CollingwoodMichael BennettLisa LindellrobertGary Lampman Recent comment authors
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Cole Collingwood
Guest

You rock…keep up the great work.

Kathy
Guest

I agree Lisa. I found this quote in another blog that aptly describes the JCHAO…
“Lately, the JC has devolved into something akin to an aging toll booth operator who lazily takes a token from every motorist who wishes to pass, with nary a glance to see if the vehicle they’re driving is actually road worthy.” this is from the HealthCare PSI Blog.
Ain’t it the truth.

Lisa Lindell
Guest

Kathy, whether they’re accredited by JCAHO or not is irrelevant. Having JCAHO accrediation is like saying they’re listed in the phonebook.

Kathy
Guest

JCAHO doesn’t accredit all hospitals. I also contacted them and the small Maine hospital my father was infected in and died as a result was not JCAHO acredited. So, obviously they were no help to me. The same hospital is now associated with a major medical center here in Maine. I am fully confident they will now be accredited and nothing about any past HAIs or errors will matter one tiny bit. Those failures involved 3 deadly infections in one single month in a 25 bed hospital. And those are only the ones I know of. My father was one… Read more »

Lisa Lindell
Guest

I wrote to JCAHO at least 4 times. I got the same letter back each time. “The hospital’s response, if any, is confidential.” Except the 4th letter said the file is closed. I monitored JCAHO’s website over an approximate 18 month period at least, they never set foot in this facility as a result of my many well-documented violations to their standards. There are many, many similar stories. Here’s an example of a sentinal event at a JCAHO facility, the child died while JCAHO was on-site doing their inspection. They didn’t do anything about it (IE: suspend accrediation status pending… Read more »

Gary Lampman
Guest
Gary Lampman

I too have contacted JACHO and asked if I could be of assistance.I’m not sure what they are doing but I found them as nothing more than a sounding Board. Taking on personnel experiences and Archiving them. They sent their standard letter that the received a reply from the Hospital and that the contents cannot be revealed for my review and /or rebuttal. Actually, Jacho acted in the same manner as the Hospital and the Department of Health. They would not discuss or allow review of the subject matter. Bev, When I have spoken about arrogance. WE know that some… Read more »

Lisa Lindell
Guest

Bev MD, I didn’t blow you off, I’ve responded to all your comments with the reality that is being a patient safety advocate. It’s not arrogant or patronizing, it’s just the facts. You should be alarmed, as a citizen of this country and no doubt a patient yourself one day, that our efforts over the years aren’t bearing results. Instead of wishing us well in our endeavors, why don’t you help us by contacting your legislators and demand mandatory public reporting of medical errors (this includes infections), demand patients be able to access their records without restrictions, demand patients have… Read more »

Michael Bennett
Guest

Bev M.D.: We’re not arrogant. We’re angry. We’re angry because we’ve lost our loved ones to a system rife with dysfunction and incompetence. We’ve been denied answers. We’ve been denied justice. We’ve been fighting against arrogance for years. So if you sense cynicism, it’s nothing personal. We just loved and our loved ones lost. And by the way, while your dispensing advice to us on how we can change the system, what are you doing to change the system now that you are retired? Most of us are not retired. And we spend countless hours and more energy than Con… Read more »

bev M.D.
Guest
bev M.D.

Lisa;
My conclusion from our discussion:
“All patient advocates are arrogant because one of them obviously already has all the answers, patronized me when I tried to be helpful, blew me off when I tried to make suggestions, and generally made it clear she has been at this far longer than I and knew much more than I did.”
Spoken tongue in cheek, of course; but sounds like something one of you might say about docs, huh? Just sayin’. I wish you well in your endeavors; I need comment no more.

LisaLindell
Guest

Bev MD, we have supported including the pt/family in RCA for years, original credit for this goes to Helen Haskell in South Carolina. When such a suggestion is made to the industry you get a deer-in-the-headlight response…and then they start telling us about our “perspective” (it’s different) and we (pt/family) don’t understand how “complicated” healthcare is. Been there, done that, still doing it. JCAHO…I appreciate your suggestions but honey, please, don’t get me started on the Joint Omission, their hands are covered in blood and the FBI needs to start throwing JCAHO executives past and present in prison. #2 is… Read more »

bev M.D.
Guest
bev M.D.

My involvment in and education re patient safety ended when I retired in 2003, so I get the increasing impression you all know more than I do. However, here’s a couple ideas, building on your comments and the quotes from Drs. Berwick and Cassel: 1. Use your joint clout to try to get the Joint Commission to require patient/family input in the process of root cause analysis, which as you know is the formal process where a hospital investigates a sentinel event or near-miss. Not that you should sit in on the whole process; the legal aspects would scare them… Read more »

LisaLindell
Guest

There’s an advocate on the east coast who was told by a hospital CEO “We don’t want to see your faces.” Because we’re the faces of their failures. Another advocate encountered the CEO of her subject hospital at an event recently. The last time she saw this CEO was at the settlement conference years earlier regarding the harm to her son. She told me it took everything she had in her to approach this CEO and say hello. The CEO had no idea who she was. The most devastating event in advocate’s life happened in this facility, changed her life,… Read more »

Kathy
Guest

Dr Bev, I agree with both of the doctors quoted. Hospital Leadership and Medical Educators just don’t “get it”. Maybe they need to recruit real life victims and/or families of victims to educate these people. They and some other professionals have no idea how their errors/neglect impact patients and their families. It is so simple for people who sit in nice plush offices or professors who no longer interact with (or even touch) patients to just slide over the cause and impact of adverse results. Those results I am referring to are death or long term disability. Somebody needs to… Read more »

bev M.D.
Guest
bev M.D.

I forgot to source my excerpted quote above:
“The Hospitalist”, Nov 2009. http://www.the-hospitalist.org

bev M.D.
Guest
bev M.D.

Here’s an interesting quote from a 10 year followup interview with 2 of the IOM’s original committee members issuing the report 10 years ago: “Q: In retrospect, what was missed in the report? Dr. Berwick: If we missed any boat in our analysis, the idea of “no blame” is not meant to relieve everyone of responsibility for medical errors, but to relocate responsibility for safety in the offices and work of leaders of healthcare institutions. The finger points to the executive suite. There’s more and more evidence that safety does not improve without the clear commitment of leaders. Dr. Cassel:… Read more »