Patient Safety - Another Look at 'To Err is Human'

Lucian Leape Adjunct Professor of Health Policy at the Harvard School of Public Health, and one of the authors of the 1999 Institute of Medicine's report To Err is Human: Building a Safer Health System, was a featured speaker last week as part of Cleveland Clinic's 6th Annual Patient Safety Forum.

The IOM report To Err is Human stated that in the US Healthcare system approximately 98,000 preventable deaths occur each year due to medical errors.  Those errors can devastate families and caregivers.  (Last year's Patient Safety Forum speaker was Sorrel King, founder of the Josie King Foundation for Patient Safety.)

During his presentation Dr. Leape noted that it can be difficult to convince physicians that safety is as serious an issue as has been reported because they rarely see cases of preventable harm in their own or their colleagues practices.  Now you may think that's simply a matter of ego, but Dr. Leape presented some noteworthy numbers that help explain that viewpoint.

There are approximately 700,000 physicians practicing in the US.  If those 98,000 deaths were distributed evenly, each physician would see only one every seven years.  Dr. Leape went on to state that these deaths are not always recognized as preventable, so a physician may only know of one occurrence of preventable death every 14 years.  One can hardly fault a physician who thinks that's not such a bad average when dealing with the complexities of modern medicine.

Until one of those 98,000 deaths touches us personally.

There has been quite a bit of recent commentary about applying airline safety standards to healthcare, and that's a discussion for another post.  However, when cockpit instruments indicate that course adjustments are needed, well-trained pilots make those adjustments even when they don't appear to fit what the pilot sees with his own eyes.

Our instruments tell us it's time for a course correction.

Comments

[Richard Smith]

Trust in a Medical Setting.

Experience dealing with a host of difficult to impossible situations may help others in their encounters with these difficult and distrusting patients. These individuals may make up a small per cent of patients and family members, probably less than 2 per cent, but take up 90 per cent of energy in coping with day-to-day conflicts that arise from their behavior. Difficulties managing distrustful patients and family members must be dealt with on the spot, and they don’t go away.
Examples come from office experiences or wards, including situations that keep doctors and nurses and therapists awake at night, aggravate waking hours and poison leisure, that is, empirical, based upon experience and observation alone without science or theory. To survive an outrageous patient or relative requires resourcefulness, patience and imagination. Street wisdom learned the hard way is what I present, and without a guide or mentor to soften the bewilderment and sense of failure and frustration that accompanies these individuals. We seldom talk about these difficult, distrustful and sometimes threatening individuals amongst ourselves; rather we suffer and endure them silently, by ourselves. The problem is timeless as recorded in the world’s literature.
Out of the wreckage of human behavior comes valued experience leading to maneuvers and tactics of survival that are appropriate to almost all aspects and settings of human interaction including day-to-day medical care.

Links:
Trust in a Medical Setting. Hauppauge, NY: Novinka Books, Nova Science Publishers, 2006.
www.novapublishers.com
richardsmithmd.com