Saturday, April 23, 2005

A C+ on Patient Safety

John Kelly, fellow grad school alum and newly minted health care management consultant, has steered me to a thoughtful and illuminating paper that appeared last November 30 in the Health Affairs web page. Written by Robert M. Wac
hter, Professor of Medicine and Chief of the Medical Service, University of California San Francisco Medical Center, it marks the fifth anniversary of the now renowned To Err is Human report issued by the Institute of Medicine.

Dr. Wachter gives the system a C+ on progress made in improving patient safety during this five-year period. He is being kind. After reading the paper I would have given it a C- or even a D+.

Dr. Wachter notes that in the modern health care environment “A critically ill patient might be seen by a half-dozen physician-specialists and scores of nurses, respiratory therapists, pharmacists, social workers, clergy and others, and receive hundreds of medications and tests.” He goes on to point out that “It should come as no surprise, then, that without a culture, procedures, and technology focused on flawless execution, errors would become commonplace.”

He attributes the lack of progress in improving safety to (a) an outdated mental model for medical mistakes, (b) collective inattention to patient safety, (c) a reimbursement system that provides no incentives for safety, and (d) a fragmented organizational structure. The outdated mental model is the one that emphasizes the importance of individuals in the provision of care and overlooks the role of systems. The fragmented organizational structure is the one that “separates the physicians from the rest of the hospital enterprise.”

He identifies the most complex issues as being: “how to promote a no-blame culture for providers who make innocent slips or mistakes while holding persistent rule violators or incompetent providers accountable, how to compensate patients for harm without necessarily invoking the heavy hand of tort law, and how to hold institutions accountable for allowing unsafe conditions to persist without hammering them in the newspapers or the courts when they acknowledge their flaws.”

Dr. Wachter has less to say about solutions, but if defining the problem is the first step, I would say his contribution is significant.

The full article can be seen at


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