Study indicates much still to be done to address patient safety

Following the Institute of Medicine (IOM) report, “To Err Is Human: Building a Safer Health System,” which highlighted the significant costs of medical error, it has become evident that the national movement to increase patient safety has fallen short.

In a study published in The New England Journal of Medicine on November 25, 2010, “Temporal Trends in Rates of Patient Harm Resulting from Medical Care”, author Dr. Christopher P. Landrigan found no substantive progress in patient safety over the 10 years since the IOM study. Conducted from 2002-2007 in 10 North Carolina hospitals (chosen for study due to notable involvement in programs to improve patient safety), the study found harms and preventable harms remained common with little evidence of widespread improvement. In these hospitals, 18% of patients faced adverse results from medical care and 63% of the injuries were determined preventable.

These statistics are staggering and reinforce the idea that there is still much work to be done in terms of addressing patient safety. The origins of preventable errors as well as the remedies that are likely to impact patient safety have been known at least as long ago as the IOM study, but have not induced widespread implementation and buy-in. Utilizing basic tools and well-known methods can even address many of these common issues and persistent problems. For example, the World Health Organization (WHO) developed the Surgical Safety Checklist containing steps that, when followed, significantly reduce the most common and avoidable risks that endanger the lives and well-being of surgical patients. Though the WHO developed this checklist and an implementation guide for healthcare organizations back in 2008 and it has been shown to significantly reduce risk and increase patient safety, it has not been implemented in the majority of hospitals.

Process changes like the Surgical Safety Checklist, however helpful they may be when implemented, are not enough without an organizational commitment. Dr. Robert Wachter, Chief of Medicine at UCSF, is quoted in the NY Times article “Study Finds No Progress in Safety at Hospitals” saying: “Process changes, like a new computer system or the use of a checklist, may help a bit, but if they are not embedded in a system in which the providers are engaged in safety efforts, educated about how to identify safety hazards and fix them, and have a culture of strong communication and teamwork, progress may be painfully slow.”

On a larger scale, therefore, the whole healthcare system has to change and we as healthcare providers need to change with it. As clinicians, our patients trust us with their health and well-being. Increasing patient safety is not simply something we should do; it is something we must do, as it is our duty to follow the classic tenet of medicine, to do no harm. It is not only about what process changes we can implement so the healthcare system works more efficiently and effectively. It is about doing right by our patients as people, individuals, and families at crucial moments in their lives.

Education is how we will take that crucial step forward to actually making a difference in patient safety. The Advanced Practice Strategies curriculum content and implementation is the lifelong clinical education infrastructure of the future, offering transformative training to every clinician where and when it’s needed. When embedded into a healthcare organization, APS continuing online education empowers clinicians with cutting edge knowledge enabling them to deliver the highest quality and safest care possible.

Dr. Martin November, Chief Medical Officer
Dr. November is an OB/GYN physician and was a member of the teaching faculty at Harvard Medical School for more than 10 years. He held various administrative positions at the Beth Israel Deaconess Medical Center including Director of the Division of Community Medicine. His academic research focused on patient safety, cost effectiveness analysis, and process improvement in healthcare. He worked with researchers at the Harvard School of Public Health on The Malpractice Insurers’ Medical Error Prevention Study (MIMEPS), a nationwide study of malpractice claims and medical errors. Prior to joining APS in 2008, Dr. November worked with the Harvard Business School Healthcare Initiative to develop the first Harvard Business School Health Science and Business Immersion Program in January 2006. He earned a Bachelor of Arts degree at Duke University, a Doctor of Medicine degree at the University of North Carolina at Chapel Hill, and a Master of Business Administration degree at the Harvard Business School.