Medical Team Meeting With Senior Couple In Hospital Room

Originally published in the South Dakota Medicine Journal, April 2018

By: Stephan Schroeder, MD, CMD, CMQ
Medical Director, South Dakota Foundation for Medical Care

The potential for harm in medical care has been known since Hippocrates.  The principle of patient safety became a significant topic of literary discussion with Dr. Lucian Leape’s 1994 pioneer commentary “Error in Medicine.”  In 1999, the Institute of Medicine publication “To Err is Human” put forth the estimate that huge numbers of Americans die each year due to preventable harm from medical care.

From there, patient safety acquired considerable attention. Multiple government and private organizations began to search to understand the causes of these errors as well as solutions to reduce preventable harm. The Patient Safety Act, enacted in 2005 with rules finalized in 2009, focuses on encouraging providers to share patient safety information through groups known as Patient Safety Organizations (PSOs).  These entities provide a framework for confidential reporting of adverse events and promote improvement in a secure environment without fear of public reporting or litigation. The Agency for Health Care Research and Quality (AHRQ) maintains updated information on PSO work.

Patient safety became an element of quality in its goal to eliminate, reduce and mitigate injury and adverse events. Safety projects were initiated to approach infection control and reduce falls and medication error rates and severity. Other concepts that have drawn attention include appropriate and timely care transition and diagnostic error.

The term ‘iatrogenic’ is used to indicate harm due to the medical system. Preventable adverse events may be due to failing to apply acceptable recommendations, and working with providers will improve outcomes in the future. Adverse events due to overt negligence are the result of cases that fall below the standard of expected care by providers or facilities. This is a more significant problem that may involve the need for punitive action. An example may be refusing to follow recommended guidelines, such as confirming patient identification or surgical “time outs.

Preventable harm has the general agreement that it is not rare or isolated. The actual number of deaths, or adverse outcomes, is less certain because measurement is somewhat controversial and research has shown varying estimates. There is no “gold standard” for measuring overall safety at an institutional level; thus, there is some difficulty in determining whether certain events are truly preventable. Regardless, there is little question there are numerous avoidable deaths and injuries that occur in all types of facilities on a frequent basis. Research has shown that catastrophic safety failures are almost never caused by isolated errors committed by individuals. Instead, they result from smaller errors within serious underlying system flaws.  The concept of a “just culture” is used to emphasize that most errors result from system failure. It is crucial that errors be reported openly and honestly, investigated thoroughly, and addressed with teamwork and collaboration.

Healthcare represents one of the most complex industries in society. Among its many pressing priorities, such as cost control and patient access, is the effort to eliminate harm, a foremost moral and ethical obligation. Improving healthcare in communities, increasing patient and family engagement, including health literacy, and maintaining financial sustainability all require a safe and stable environment. Obtaining this “just culture” of patient safety is a daunting challenge.

Ongoing challenges in patient safety include antimicrobial stewardship, opioid abuse, adverse medication events and timely assessment with appropriate care levels that follow acute hospitalization. Standardized measurement criteria for errors, especially with the goal of accurate clinical diagnoses, will need development. The future seems to lie in promoting a safety culture in which we all learn from adverse events.  This will help us follow that primary principle of “First Do No Harm.”