Sunday, August 9, 2009

Baby steps

Today, Hearst newspapers published a series of reports, Dead by Mistake, about how often people in the United States die as a result of seeking healthcare. It's a big number.


The same number--widely seen as an underestimate--that's been floated for the past 10 years when the first comprehensive national report on patient safety was published. Today's Hearst piece added an updated comparison (in the event that comparisons to deaths from AIDS; breast cancer; and auto accidents are insufficient for illustrating the magnitude of the problem). In one month, more people die as a result of medical errors and healthcare acquired infections than died on September 11th. For the record, these iatrogenic events continue to kill more people than AIDS, breast cancer, and auto accidents. Combined.

One article published the Albany Times Union provides an excellent recap of where key improvement measures, recommended nearly a decade ago, stand today. It's worth a read whether you're a seasoned observer of medical misadventures or are just beginning the journey.

I'm in the "seasoned" crowd, and there's something in the Hearst reporting that, while not progress in and of itself, may at last be signaling change, paving the path where progress will ultimately travel.

The piece is amply illustrated by the tragic stories of individuals whose lives have been lost or forever changed as a result of medical error. The profound feelings of grief and betrayal experienced by affected individuals hasn't changed, and won't change, until there are no more stories to tell. But what does seem to be changing is a shift in perception about where the opportunities for improvement rightly lie.

When the public demands and institutions support the notion that individuals can be made to perform flawlessly, progress--in any endeavor--is stymied. Individuals can never be flawless, and from a mathematical standpoint, the performance of individuals organized within a system can't be made flawless either. But the odds of disaster when individuals work within well-constructed systems can be reduced to a near-negligible point. This is a guiding principle in industries, such as commercial aviation and nuclear power, that reliably produce an intended, and expected, result.

The Hearst report is rife with criticisms, rightly centered on infrastructure and process defects. High-end individual performance by front line clinicians can only be predicted to occur, and reoccur, when seated within work processes designed to, well, work. The report is noteworthy in its mention of such things as:
  • negative consequences arising from a decade-long failure to establish a comprehensive, nationwide error-reporting system
  • how a lack of organizational transparency hamstrings patients, as pure consumers of care and in the aftermath of an adverse event
  • the consequences when hospitals make full adoption of NQF's Safe Practices a low-priority item
Focusing on system weaknesses means giving up the idea that a Sam Smith, RN or a Jo Jones, MD killed someone (and 97,999 other someones every year). It looks instead at what's available when one Sam or one Jo isn't up-to-snuff, up-to-speed, or up-to-date, and builds a system that allows patients to survive when human fallibility is unmasked.

If a journey of a million miles begins with a single step, we may have seen the first one taken this morning in the Albany Times Union. And we'll soon see if the baby really can walk when we see how patient safety is prioritized in the healthcare reform we're about enact.

1 comment:

Cockroach Catcher said...

"Primum non nocere"---First, do no harm.

The Cockroach Catcher

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