During the pandemic, heightened safety precautions are needed more than ever
By Seth Freeman
On Thursday, September 17, in the midst of a global pandemic, the World Health Organization will observe International Patient Safety Day with presentations by President Bill Clinton along with other prominent political leaders, medical professionals and entertainment celebrities. The event recognizes a major problem in health care, presently exacerbated by the coronavirus epidemic. It has been a long time coming.
Over two hundred twenty years ago, in the wee hours of Tuesday morning, December 14, 1799, after feeling unwell the day before, George Washington awoke with a sore throat. His doctors and caretakers, eager to be helpful and confident in their expertise, drained over forty percent of the former president’s blood and swabbed his throat with a preparation of dried beetles. The country’s founding father died in agony.
Until the early part of the Twentieth Century if you were sick or injured, you were more likely to die if you visited a doctor or a hospital than if you stayed home. In ancient Greece, Hippocrates had tried to teach physicians, “First, do no harm.” Through the ensuing centuries many practitioners failed to get the memo.
In the late 1990s Hippocrates’ basic precept was reaffirmed, in the form of a dramatic, watershed report from the Institute of Medicine’s Committee on Quality of Health Care in America, To Err is Human: Building a Safer Health System. The report, preceded by two studies placing the number of deaths in the U.S. due to medical mistakes at between 44,000 and 98,000 per year, inspired today’s dynamic patient safety movement. A more recent study checking on how we are doing since those seminal reports found that the real number of deaths in the U.S. due to medical error is closer to a quarter of a million, the third leading cause of death, until it was recently surpassed by Covid-19. This latest assessment does not necessarily mean we are doing worse. It is more likely that, with the new focus on safety, more of these incidents, always with us, are now being accurately reported.
The safety movement in health care profited from successful innovations in safety protocols in other fields, especially air travel. Following the 1977 collision of two jumbo jets on the runway at Tenerife airport in the Canary Islands in a dense fog, killing 583 and injuring another 61, the airline industry developed a powerful, creative methodology for enhancing flight safety. In the new approach near misses were investigated as seriously as actual accidents. The traditional cockpit hierarchy was relaxed, empowering crews to raise safety concerns. Rigorous checklists were instituted, and wherever possible, changes were made to processes, rather than just disciplining or retraining people. The goal was to make the entire system itself less vulnerable to error.
Excellent hospitals across the country now have robust patient safety departments. In Southern California, UCLA Health participates in an effective initiative called “High Reliability/Zero Harm.” Zero Harm? In an environment with hundreds of thousands of mistakes is the goal of zero harm even remotely realistic? Anne Marie Benedicto of the Joint Commission Center for Transforming Healthcare points out that, “We thought we could never eradicate [healthcare-acquired infections like central line infections or ventilator-associated pneumonia]…Now, we’re actually seeing organizations get to zero harm for long periods of time for those specific infections… it really is possible.”
Health care functions at the intersection of the most complex systems on the planet — the human body, modern medicine, the health care system itself. For most quality hospitals achieving high reliability is centered around three core elements: a leadership committed to zero harm, a culture of safety in which all participants feel empowered to speak up when something appears not right, and a data-driven focus on improving processes. In the new safe care environment clinicians are encouraged to “fess up when you mess up.” Instead of blame and shame, the focus, like that of the air travel industry, is on improving processes.
It is heartening to observe today’s clinicians meet these challenges seriously, creatively, with intelligence and deep caring. At UCLA Health, in fact, taking a non-punitive approach is only the first step. The medical center goes farther, recognizing awareness and attention to safety with a monthly award given for the most significant “good catch,” in which an adverse event has been avoided by sharp clinical thinking. In most months, there are so many great instances of alert care that it is difficult to choose only one which merits the award.
During the worst pandemic in a century, with clinicians battling an imperfectly understood, highly contagious disease, often in under-resourced settings, the already numerous opportunities for error are accelerated, adding unprecedented challenges to a stressed system. The world’s forceful recommitment to patient and clinician safety and to combating the ancient scourge of medical error, as recognized by WHO’s International Patient Safety Day on the 17th, could not come at a more perfect — or more critical — time.
Seth Freeman, MPH, is a multiple Emmy-winning writer/producer for television, a playwright and a journalist.