Thursday, March 12, 2009

Patient Safety: Is it really like baseball, hotdogs, apple pie & Chevrolet?

Happy Patient Safety Awareness Week! We're at the tail end of the nation's weeklong campaign designed to spur conversation amongst consumers and providers and promote strategies to make patients safer.

I don't know what the celebrations look like where you are, but most people I know are talking about worrisome first quarter financial projections, rising unemployment, and the possibility of many more people joining the ranks of the uninsured. It's exceedingly tough to be an effective advocate for patient safety these days, a concern reflected in the theme chosen by the National Patient Safety Foundation for their 2009 spring meeting: "Patient Safety in Challenging Times: Now More Than Ever, a Critical Need."

I've found that Wikipedia entries often offer simple words that capture complex ideas, so I tooled over and was happy to find this definition at
"Patient safety is a new healthcare discipline that emphasizes the reporting, analysis, and prevention of medical error that often lead to adverse healthcare events."

Thank you, Wiki, for a step in the right direction. Because it seems to me that part of the "patient safety" advocacy problem may be rooted in its warm, fuzzy name. "Patient safety" sounds like a simple "mom and apple pie" issue. I'm for it! You're for it! We're all for it! Who wouldn't be for patient safety?

(Just for fun, picture yourself, a colleague you respect, or your personal physician in a very public forum--let's say "on the news" or "under oath" to set up a visual. Now imagine the question, "So, do you or do you not embrace patient safety?") There really is only one right answer.

But can everyone who can honestly say, "I'm for patient safety," also say, "I'm committed to a process in which real or potential error is reported and deconstructed, where failure points are identified, and, when necessary, to the redesign of work processes to prevent recurrence of an error or event"?

Really being for "patient safety" requires more than good will, a caring heart, or a pledge to "do no harm." In order to diminish inadvertent harm, seasoned clinicians have to examine, and sometimes leave behind, elements of dearly-held, intention-based beliefs and practices. ("The Five Rights" may not make it through process mapping and meticulous work flow redesign.)

In the end, these clinicians, whose valuable expertise arose in a different tradition, will likely adapt processes and methodologies, borrowed from high stakes industries with superior safety records. A new generation of "digital natives" will join our ranks, bringing new norms and new ways of taking on and solving complex problems. Reliability in healthcare will improve. But this is a process, not an event.

To answer, "Yes, I'm for patient safety," healthcare managers, administrators, and payors must embrace the emerging science that informs safety, invest in high-yield products and processes, and nurture widespread culture change. Again, a process, not an event.

Investing in better processes is still investing, and "patient safety" may be a hard line item to defend in a tough economy. So as National Patient Safety Week comes to a close and the inevitable rounds of budget cutting begin, I hope I've left you with a user-friendly assessment tool. Just ask, "Are you really for patient safety?"

Stay safe and come back soon!

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