Published by: Gerald Early on 3/8/2013 10:38:46 AM
In recognition of Patient Safety Awareness Week (March 3-9), the NAPH Safety Network will feature posts from staff at member hospitals. The NAPH Safety Network is a Partnership for Patients hospital engagement network that aims to reduce nine preventable hospital-acquired conditions by 40 percent and 30-day readmissions by 20 percent by 2013.
These Latin words, translated as “first, do no harm,” are easy to embrace. We do this difficult work because we are answering a calling or serving a mission, and that’s some of the reason we’re embarrassed by medical error.
The problem is not small. Wrong patient, site or procedure errors occur five to 10 times per day, and 37 percent of hospitalized patients experience an adverse event. There are as many as 2 million hospital-acquired infections per year, and 44,000 to 98,000 deaths each year are due to preventable error. There is growing recognition of the size, ubiquitous nature and impact of health care safety issues, and society is asking us to make it better.
So, if we recognize the extent of the problem and we agonize over the impact, why is it so hard for us to bring about improvement? Some of the answer lies in the words of Don Berwick, “The vast majority of medical mistakes are committed not by bad apples, but by good people trying to do the right thing, working under conditions that do not account for the fact that they are human.”
The human condition includes limited memory capacity, limited ability to multi-task, innate cognitive errors such as tunnel vision, and the effects of distraction and stress. The medical culture, however, has evolved to ignore the limitations of our humanness, and utilized a punitive approach when defects are discovered. Our culture rewards the appearance of perfection and punishes error. This results in missed opportunities to learn from error and has hampered improvement in patient safety.
If we’re going to make it better, we have to shift our focus from figuring out who to blame to a focus on building systems that compensate for variability and humanness. We need to design, implement and promote systems that will make it easier to choose the best thing and that will compensate for drift and divergence.
The work that you do every day to build safer health care systems is monumental. Margaret Mead said, “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.” You are doing that. Never doubt the value of the work you do for patient safety. Few people get to save a life; but you’ve done it--more than once.
Have a great Patient Safety Awareness Week!
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Gerald L. Early, MD, MA
Medical Director, Patient Safety
Chief, Surgical Critical Care
Truman Medical Centers
Kansas City, Mo.