Last month marked the 20th anniversary of the landmark Institute of Medicine report “To Err Is Human: Building a Safer Health System.” The report proved to be a turning point, with hospitals and healthcare professionals across the country became even more committed to better, safer, more patient-centered care. This was particularly true in South Carolina, where initiatives like Safe Surgery 2015 and SCHA’s Zero Harm program alongside collaborative efforts like the Birth Outcomes Initiative and the Behavioral Health Coalition illustrated how our hospitals were coming together and thinking collectively about the health and safety of their patients.
Two decades later, our healthcare system in South Carolina and around the nation continues to evolve and transform, but the goal of providing all patients with high-quality, safe and individualized care remains front and center, a testament to To Err’s lasting impact.
SCHA asked one of our state’s most dedicated patient safety advocates, Dr. Danielle Scheurer, Chief Quality Officer at MUSC, to reflect on the impact of the report from her perspective in 2019.
How did you start focusung specifically on patient safety?
DS: I got started in safety more from the operations side, as a director of general medicine at Brigham and Women's hospital; there I started basic care and process standardization (such as checklists and interdisciplinary rounding) and found safety parameters improved. With some early wins and excitement, I realized how much I loved implementation science, and seeing safety improvements, so that was my first early love for safety.
Thinking back twenty years to the time when To Err is Human was published, how would you describe the state of quality and patient safety in South Carolina (or your health system specifically)?
Is it much more standardized and organized than in years past. We have a solid foundation of a culture of safety (learning culture, just culture, and reporting culture) where we are more likely to find a near miss than we are to find a harm. That is incredibly inspiring and should give us all hope for the future.
What kind of immediate impact did To Err is Human have on your work or field?
It was a jolt that really shed light on how much non-standard work and unsafe processes we had long tolerated in healthcare. There just isn't the same tolerance for that now than there used to be.
Reflecting back on it twenty years later, what is the most surprising or interesting development in patient safety work that you’ve seen in South Carolina?
The culture change work has been the most interesting and most impactful. Without a safety culture it is not possible to actually change the trajectory of safety in healthcare.
Given how much things have changed (or haven’t changed) over the last twenty years, what do you see as the most likely (or most pressing) innovation we need to see in the next twenty years?
We need better "virtual care" teamwork and communication, with the ability to fully care for patients wherever they are and whatever their care needs are; I believe patient care can be safely delivered in many locations and is best closest to "home." We have the capability to do this better than ever with virtual care options, but the complex teamwork and intra-team communications has to keep pace with the technology capabilities and patient demand for local and "on demand" care. Without better teamwork and communication, we run the risk of further fragmenting care.