Progress and Pitfalls 10 Years After "To Err is Human"


[Tonight], I will drive up to Charlotte and get on an airplane. I will know that the food is going to stink. I will know it will be uncomfortable. But I will have absolutely no concern that I will be harmed in the process of flying back to San Francisco. Today . . . there must be tens of thousands of patients checking into the hospital. They also know the food’s going to stink. They also know they’re going to be uncomfortable. But they are, I can guarantee you, scared that they will be harmed or killed in the process of getting care. I commend you on what you’re doing to fix that. I think we’ve made tremendous progress, but I think we still have a ways to go until they have the same feeling coming into your hospital as I will getting onto an airplane. Robert Wachter, MD, concluded his presentation on “Patient Safety Ten Years after the IOM Report on Medical Errors: Unmistakable Progress and Troubling Gaps” with this thought-provoking twist on the familiar comparison between safety practices in aviation and health care at the 4th Annual South Carolina Patient Safety Symposium.

Wachter, who serves as chief of medical service at the University of California, San Francisco (UCSF) Medical Center and associate chairman of the UCSF Department of Medicine, reviewed the progress of the U.S. health care system since 1999 when the Institute of Medicine (IOM) released the report that forever altered the safety and quality landscape. He noted several roadblocks that initially hindered improvement efforts. These include a longstanding mental model focusing on individual fault rather than systems thinking, a lack of expertise in analyzing errors and fixing systems, no infrastructure and little research from which to draw. He also pointed out that while there was and continues to be an obvious ethical case for focusing on patient safety, no business case existed.

With a decade of work under its belt since the IOM report, Wachter said the health care industry now has a sense of which safety improvement strategies have worked well and which have not. Even with this new knowledge and greater political pressure to improve, one difficulty remains. “Most of the activities we’re asking you to do will come from your bottom line,” he pointed out.

An academic, Wachter turned to the method of communicating improvement that he uses every day. He “graded” the health care field’s use of four categories for change to promote safety and quality.

• Regulations, such as the Joint Commission, scored a B+. Wachter praised the change to unannounced surveys and tracer methodology, but contended that a centralized regulatory or accreditation solution “runs out of gas” after low-hanging fruit has been claimed. For example, he contrasted the original National Patient Safety Goals (NPSG-sign your site, high-risk abbreviations, etc.) with the new NPSGs dealing with leadership standards and disruptive providers, which are much more nuanced and sociocultural and thus less well suited to regulation. “It’s hard to regulate culture,” Wachter notes.

• Reporting Systems also rated a B+. While cautioning that reporting has no intrinsic value on its own, and that attempts to report every single error and near miss are not useful and can result in data overload, Wachter said he believes public reporting has led to some progress. 

• Clinical IT scored a C+ not because of a lack of progress, but because the juxtaposition of “still-clunky” health care IT systems is jarring when compared with how well IT functions in the rest of our lives. He also considered unforeseen consequences and errors actually caused by IT systems.

• Balancing “No Blame” and Accountability garnered another C+ and much of Wachter’s presentation focused on these two “competing epiphanies.”  He warned that naming everything as a systems problem is hurting health care’s credibility, and that while no blame needs to remain the dominant frontline culture, there must be a clear demarcation of blameworthy acts.

Overall, Wachter gives health care a grade of B- which, compared to the F he would have given 10 years ago, indicates that considerable progress in patient safety and quality has been made. “That said,” he notes, “when my kids come home with a B- from school, they still get a pretty stern talking to.”

Click Here to See Robert Wachter's Presentation with Slides

05-18-2011 10:14 (EDT)