Is Patient Safety Part of Something Larger?
I keep seeing examples of what I think of as a patient safety approach to problems: an emphasis on clear communication, teamwork, systems thinking, disclosing and learning from errors, and personal accountability balanced with an understanding of the inevitability of human error. These principles have relevance and benefits beyond patient safety — beyond medicine — and often have deep roots in other disciplines and knowledge. I’ve developed a sense that patient safety is but one door — my door — into a way of understanding the world, which others may enter through other doors.
In the next issue of Patient Safety & Quality Healthcare (available here the week of Feb.1), I write about an example of error analysis that’s consistent with what I think of as patient safety principles. In The New York Times earlier this month, David Leonhardt analyzed factors that contributed to the economic crisis using phrases that, for me, conjure safety improvement literature:
[Bernanke] and his colleagues fell victim to the same weakness that bedeviled the engineers of the Challenger space shuttle, the planners of the Vietnam and Iraq Wars, and the airline pilots who have made tragic cockpit errors. They didn’t adequately question their own assumptions. It’s an entirely human mistake.
Leonhardt goes on to call for open discussion of these failures so that we might learn and not repeat them. He comments that we would benefit from having the equivalent of the National Transportation Safety Board for financial institutions, a recommendation that also has been made about patient safety. It’s no secret that the patient safety movement has benefited from borrowing what other industries have learned about safety and quality. Still, I was struck to find familiar language applied in a very different setting.
Another example of something that’s recently reminded me of patient safety principles comes from medicine. In Death Foretold: Prophecy and Prognosis in Medical Care, Nicholas Christakis explores error, adverse events, accountability, and communication between physicians and patients. In all my reading and discussion of medical errors in the past 5 years, I have not heard anyone refer to a missed or faulty prognosis. I don’t suggest that we should view prognosis errors the same way we view incorrect diagnoses, but Christakis’s attention to error has greatly enriched my understanding, in large part because he isn’t traveling in the patient safety “waters” with which I’m most familiar. His exploration of prognosis is a good reminder that medicine is much more than science; in fact, his research and analysis tease out a rich appreciation for the complexity and psychology of error:
Physicians’ attitudes toward prognostic error are complex, however, and not simply restricted to aversion. On the one hand, any prediction entails the possibility of error, and a prediction which is unduly favorable may be perceived as a professional failing. On the other hand, developing and communicating a prognosis can be a way for physicians to avoid errors in their clinical practice, because if they can make correct prediction, they can avoid unexpected occurrences, especially bad ones. (pg. 65)
Explanations of outcomes originate in the desire of patients and doctors alike to understand what has happened and to find meaning in medical events. There is a special desire, however, to find meaning in unexpected outcomes. (pg. 76)
It’s interesting to note that Christakis’s book on prognosis was published in 1999, the same year that the Institute of Medicine released (in November) the report, To Err Is Human, which launched the patient safety movement, another reminder that patient safety has been my door into knowledge and awareness that predates the movement itself.
My final example of patient safety principles at work elsewhere in the world is the “empowered patient” or “participatory medicine” movement, which shares many goals with patient- and consumer-led groups working to improve patient safety: improved communication, transparency, accountability, and mutual respect between patients and providers. As far as I can tell, participatory medicine and the patient safety movement have been running on parallel tracks for years, with recent, important intersections. For example, one of participatory medicine’s most prolific and inspiring advocates, Dave deBronkart, known as ePatientDave, recently has attended events held by MITSS (Medically Induced Trauma Support Services) and the Lucian Leape Institute at the National Patient Safety Foundation (NPSF) and he is scheduled to speak at NPSF’s 2010 National Patient Safety Congress. The cross-fertilization and silo-busting are all to the good.