Sunday, November 22, 2009

Patient safety 10 years after “To Err is Human”

Commentary from key leaders in the latest issue of The Hospitalist reflects on where we've come in the decade since the Institute of Medicine released its patient safety report. Though the article is mainly congratulatory there has been spirited debate about the success (or lack thereof) of the patient safety movement. A recent report by the Consumers Union declared the movement a failure. Although the report lacked data on safety breaches and was based on a faulty premise (equating the continued high rate of hospital associated infections to unsafe practice) it correctly pointed out that we have done little to implement the IOM's recommendations.

Why haven't we done more? Maybe because the IOM's recommendations were predicated on a culture of transparency while over the past decade we have devolved into a culture of blame. These are mutually exclusive outcomes. I pointed that out here and in other posts as my own reason for giving the movement a failing grade.

Meanwhile Bob Wachter gives the patient safety movement less than glowing reviews but apparently for the opposite reason. He seems to believe we have achieved a no blame culture and not only that, it has gone too far. He opened his September 30 blog post with:

In this week’s New England Journal, Peter Pronovost and I make the case for striking a new balance between “no blame” and accountability. Come on folks, it’s time.

Why the seemingly divergent conclusions? Because we've conflated the ideas of accountability and blame. Blame is finger pointing when something goes wrong. The ad below reflects our culture of blame. Note the implied finger pointing: if the patient gets VAP it's someone else's fault.

That's the attitude that pervades medicine today and it's so counterproductive! But it's not the accountability Bob's talking about. If we make careful distinctions between accountability and blame Bob and I are not that far apart. He believes there should be consequences for stubborn, deliberate violation of known safety measures such as hand washing and time outs. I couldn't agree more. It's a form of disruptive behavior, for which Joint Commission already requires “zero tolerance”.

Low blame and high accountability are not conflicting goals. What we have now is too much blame and not enough accountability! In its report the IOM noted that transparency would be essential to effective process improvements for patient safety. The report also stated that such transparency would require movement toward a blame free culture. But, due to misinterpretation of research data and a blunder in the use of language the IOM report had the opposite effect! I explained here:

Ironically, the IOM, with the issuance of its report, undermined its own aspirations for a culture of transparency right out of the gate! They did this by indiscriminately referring to a broad spectrum of adverse patient outcomes as “errors.” This unfortunate attribution, based on faulty analysis of a landmark study on adverse hospital events, I have argued, did much to sabotage the cause of patient safety in the decade that followed. (For the original investigator’s own criticism of the IOM’s interpretation see this editorial). Instead of an era of transparency we entered a heightened culture of blame and finger pointing. The most vivid example of this, of course, is Medicare’s never events policy, of which we are just beginning to realize the adverse consequences.

Now we have a domino effect of more and more unintended consequences. Already in the works is a new legal standard which shifts the burden of proof to hospitals in certain malpractice cases. So much for transparency!

At a recent UWGrand Rounds presentation Bob described what he called a “masterful bit of spin” by the IOM in equating the rate of adverse events in health care to one commercial air crash per day. But the IOM did worse than spin data. They spun assumptions based on faulty interpretation of data. Masterful but unfortunate.

No comments: