A Point of View
Talking about Patient Safety: Lessons to be Applied from the Third Annenberg
Conference
Anne G. Matlow MD, FRCPC
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Those who attended the third Annenberg conference,
"Let's talk: communicating risk and safety in health care,"
have an urgent message to share: it's time for more Canadian
physicians to start talking about patient safety. The conference,
jointly convened by the U.S. National Patient Safety Foundation,
the Annenberg Center for Health Sciences at Eisenhower, the Joint Commission
on Accreditation of Healthcare Organizations, the American Association for
the Advancement of Science, and the U.S. Department of Veteran Affairs, was
one in a series addressing "issues vital to enhancing patient safety and
reducing errors in health care." Although the safety movement is still
nascent, the accompanying tides will not turn. We in Canada must also be
talking about patients' safety.
The publication of the Institute of Medicine's (IOM) report served as an
alarm throughout the U.S.1 It was estimated that 44,000 to 98,000 excess
deaths due to medical error occur annually, and that injury to patients
occurs even more commonly. This figure has been likened to the equivalent of
one jumbo jet going down every one to three days. Would anyone tolerate that
from the aviation industry? Experts in the field of medical error are
starting to understand that "memory and attention to detail are especially
vulnerable to failure — even among well trained, intelligent, and committed
health-care professionals."2 The push is on to change the design of health-
care systems and processes, to promote patient safety, and to acknowledge
human vulnerabilities. A change in focus is thus shifting the emphasis, and
hence, the nomenclature from "medical error" to "patient safety." It will
behoove us as physicians to adapt to these changes.
A quote firom George Bernard Shaw underscored the complexities that formed
the conference's premise. "The greatest problem of communication is the
illusion that it has happened." A compelling video produced by the American
Medical Association showed that the expectation that patients comprehend
diagnoses and treatment plans related to their care is generally
overestimated given the degree of health illiteracy in the community. The
timely report3 about illiteracy in Canada as a public-health concern
underscores the urgent need to address this problem in our backyard.
Once we accept the fact that errors do occur, the question of whether an
error should be disclosed to the patient and family becomes an extension of
the deliberations. After hearing the stories of three individuals who had
lost loved ones to medical error, one emerged with the conviction that from
the family's point of view, prompt disclosure is paramount. Wu has reported
that "close to half of malpractice cases could have been avoided through
disclosure or apology but instead were relegated to litigation....What the
majority of patients really wanted was an honest explanation of what
happened, and if appropriate, an apology."4 To foster this, the medical
institution must create a blameless reporting structure. In his presentation
at Annenberg III, Wu noted that the benefits of disclosure for the physician
include creating a sense of relief, strengthening the relationship with the
patient, reducing the risk of litigation, and allowing for learning. To that
end, Hébert et al have published an excellent review of the ethical, legal,
and practical aspects of disclosure, which includes proposed guidelines.5
Lucian Leape, a pioneer in the field of medical error, has noted that to
create a comprehensive approach for enhancing patient safety, we need to
veer
from dwelling on "human failures," and learn from disciplines that
understand
behavioural and systemic changes.6 Paul Slovic, president of the Decision
Science Research Institute in Oregon, presented lessons for risk
communication from cognitive science. In relaying the importance of trust
and
its fragility, he quoted Abraham Lincoln: "If you once forfeit your
confidence in an individual you can never regain their self esteem." Other
speakers discussed the relevance of the principles of behavioural science to
teamwork in the health-care environment. Many systems-related causes of
medical error were discussed, including interactions with technology, large
numbers of hand-offs among health-care staff, poor patient-to-staff and
staff-
to-staff communication, stress, fatigue, human factors, design flaws, higher
acuity of illness, reductions in staff, and the lack of appropriate
education.7 Although only a short focus at the end of the meeting, it was
acknowledged that the training of upcoming health-care professionals may
offer the greatest opportunity to create a new generation of caregivers who
will help shape the future of health care.
The curriculum of the future might highlight innovative elements including
teamwork skills in and across disciplines, the methods of effective
communication, risk assessment and management, and professional
accountability. The use of realistic medical simulators8 offer an
opportunity
for practice, preparation for emergencies, and ongoing competency training.
The adage "see one, do one, teach one" would not be an ethos in the new
curriculum, but might apply in low-risk situations or if providers'
competence and patient safety were ensured. Mutual respect for other members
of the health-care team might be heightened after a rotation outside one's
discipline (for example, with pharmacy or nursing).
For physicians, tackling the problem of patient safety will require an
attack
from both ends. We need to create a forum where practising physicians are
reminded of and can learn old skills in what may be a new context. We also
need to create a blameless reporting structure. Physicians in turn must
appreciate their position as role models, and the need for them to "walk the
talk." Medical-school admissions boards and educators have to decide whether
the ideal profile of the physician-product from the new curriculum warrants
reassessment of current admission criteria. And finally, we must recognize
that the perfection of technical and communication skills is as important as
evidence-based medical guidelines in ensuring the practice of the highest
quality in both the art and science of medicine.
The challenge of making health care safer will not be solved overnight. And
it will not be solved in a medical vacuum. "There is a vast reservoir of
study and experience, both in health care and outside of it, that can inform
those who set about to change their systems to make them safe."9 Change must
be preceded by an awareness of the issues. It is time for us all to be
talking about patient safety.
References
Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a
safer health system. Washington: National Academy Press, 1999.
Weingart SN. Patterns and causes of medical error. In: Zipperer L, Cushman
S,
editors. Lessons in patient safety. Chicago: National Patient Safety
Foundation, 2001;7-13.
Weir E. Illiteracy as a public health issue. Can Med Assoc J 2001;164
(10):1486.
Wu AW. Handling hospital errors: is disclosure the best defence? Ann Intern
Med 1999;131:970-2.
Hébert PC, Levin AV, Robertson G. Bioethics for clinicians 23. Disclosure of
medical error. Can Med Assoc J 2001;164(4):509-13.
Leape L. Error in medicine. JAMA 1994;272:1851-7.
Loeb JM. An environment prone to error. In: Zipperer L, Cushman S, editors.
Lessons in patient safety. Chicago: National Patient Safety Foundation,
2001:37-9.
Barach P. Patient safety curriculum. Acad Med 2000;75:551-2.
Leape L. Foreword. In: Zipperer L, Cushman S, editors. Lessons in patient
safety. Chicago: National Patient Safety Foundation, 2001:xiii-iv.
Received June 8, 2001
Accepted June 11, 2001
Address for reprints: A.G. Matlow, The Hospital for Sick Children, Rm. 7326,
Black Wing, 555 University Ave., Toronto ON M5G 1X8, e-mail
anne.matlow@sickkids.ca.
© The Royal College of Physicians and Surgeons of Canada
December 2001 contents
Web page updated: 17 December 2001
