Editor’s Notebook: Scale

March / April 2010
Editor’s Notebook



My email and Twitter accounts are full of news about Patient Safety Awareness Week (PSAW; March 7–13), which has been sponsored by the National Patient Safety Foundation (NPSF) since 2002. In an interview with Heather Comak of HealthLeaders Media, NPSF President Diane Pinakiewicz explains that the purpose of PSAW is “…to provide a week not just for heightened awareness about patient safety, but very specifically a focus on the role of the patient and consumer in the work.” The theme of PSAW for 2010 encourages consumers and providers to improve communication: “Let’s Talk: Healthy Conversations for Safer Healthcare.”

I’ve often written about the role of the patient in improving patient safety, usually in the context of hospitals, where patients and family members or trusted advocates actively observe and communicate with physicians, nurses, and other staff members. Recent reading reminds me that clinicians and staff members also usually act as individuals as they attempt to improve patient safety. Like patients, they do their best to do what they can to make a difference. There are powerful examples of all kinds of individuals — consumers, family members, clinicians, administrators, entrepreneurs — who have achieved significant advancements. Their work is limited, however, in that it is required but not sufficient for lasting system change and improvement.

Most of what I’ve read recently about PSAW — from traditional media as well as bloggers and on Twitter — relates anecdotes about local activities across the country: poster competitions, educational games, and reminders about maintaining personal medication lists.

Other reading reminds me that much larger forces underlie safety problems and must be engaged for effective improvement. On March 10, 2010, the Health Affairs blog published “Radiation Hazards Illustrate Need for Industry-Wide Safety Response” by Dr. Peter Pronovost, in which he reflects on a recent series in The New York Times on radiation safety. Pronovost and six co-authors call for increased scrutiny of medical devices, including radiologic devices, starting with original design and engineering. They also refresh their earlier call to promote patient safety with a public-private partnership that would include all stakeholders, including device manufacturers, and operate on a national or global scale.

Pronovost et al. point out that patients are harmed one by one. Despite occasionally intense media focus on certain events — the Quaid twins’ medication errors, for example — most patient safety incidents are unknown except to those immediately involved. The effect of medical error is felt by individuals, and too often the solution also is left to individuals.

More evidence of the need for bold, system-wide improvement comes from the Lucian Leape Institute at NPSF. In a report also released on March 10 (see pg. 58 in this issue), the Institute calls out medical schools for failing to train physicians to provide safe care and challenges them to follow 12 far-reaching recommendations.

Each annual PSAW reaps great benefits for individuals and hospitals, and at the same time, some of the most respected voices in patient safety are reminding us that local improvements must be bolstered by change on a grand scale.