Fifty Years of Patient Safety: Are We Making Progress?
Over the last century, healthcare has seen sweeping change, with transformation in medical education, policy, and regulation. Unfortunately, the impact of these changes on patient safety is not entirely clear, because preventable harm to patients was not labelled, measured, or reported systematically until relatively recently. A turning point occurred in the late 1990s, when mounting public concern about safety in hospitals ignited a call to action. The landmark Institute of Medicine report To Err is Human (1) cited earlier research estimating that over 100,000 Americans were dying annually from medical error (2). The National Patient Safety Foundation (3) and the Canadian Patient Safety Institute (4) were created, and Baker and colleagues published the Canadian Adverse Events Study.5 Hospitals began to adopt a ‘systems approach’ to analyzing safety events and more open disclosure to patients and families. Quality improvement collaboratives such as SaferHealthcareNow! emerged. In pediatrics, early adopters established connections through groups such as the CAPHC Patient Safety Collaborative (6) and the Pediatric International Patient Safety and Quality Community (PIPSQC).(7) In 2012, a Canadian group led by Dr. Anne Matlow, supported by CPSI and CAPHC published the world’s first national study on the epidemiology of preventable harm to hospitalized children(8).
From 2003 to 2016 the CAPHC Patient Safety Collaborative met on the 4th Friday of every month. This was a national forum that united individuals, groups and organizations to facilitate partnerships, improve communication and when appropriate undertake collective action to improve patient safety for all children and youth. The sharing and learning that took place through this collaborative has now extended into all CAPHC programs, with patient safety being an overarching principle of their work.
The exuberance that characterized the launch of the patient safety movement had important and lasting impacts: health professionals of every discipline began to take up safety science as a career focus, education programs to build capacity proliferated, patients and families joined partnered in advocacy, and healthcare leaders began to learn from industries with the best safety records. Attitudes shifted, with concepts like the “swiss cheese” model9 becoming common knowledge within a generation. Tactical strategies aimed at reducing harm proliferated through innovation, research, and implementation: early warning scores, rapid response teams, sepsis protocols, smart pumps and computerized provider order entry to name but a few.
So, how much progress are we making? Despite this energy and activity, leaders in patient safety agree that progress in eliminating preventable harm is proving slower than hoped. Recent reports such as the NPSF’s Free from Harm(10) and Ross Baker’s Beyond the Quick Fix,(11) speak to insufficient focus on leadership and culture in the early phase of the patient safety era. It is clearer to us now that safety cannot be a project delegated to ‘the safety person,’ and all of the promising strategies and tactics are truly ‘eaten for lunch’ by culture.(12)
Should we be discouraged? Absolutely not. Far from daunted, pediatrics is leading the way toward a bright future for patient safety. Highly organized groups are achieving large scale improvements in areas like neonatology(13) and team communication.(14) Solutions for Patient Safety,(15) a collaborative of over 130 children’s hospitals, including 7 Canadian organizations, is transforming safety through a focus on leadership and culture. Pediatric surgery programs are sharing outcomes data in the spirit of improvement like never before.(16)
The audacious goals at the launch of the patient safety movement could be characterized as naïve in retrospect. A better analysis is that these goals were based on optimism and a sound moral imperative, and with the maturation of the movement, we now know better what needs to be done to eliminate harm and are poised to do it.
Trey Coffey, MD, FAAP, FRCP(C), Medical Officer for Patient Safety, The Hospital for Sick Children, Associate Clinical Director, Children's Hospitals Solutions for Patient Safety (SPS)
- Cohn and Corrigan. To Err is Human. Institute of Medicine 1999.
- Brennan et al. Harvard Medical Practice Study. N Engl J Med 1991.
- Baker et al. Canadian Adverse Events Study. CMAJ 2004.
- Matlow et al. Canadian Pediatric Adverse Events Study. CMAJ 2012.
- Reason 1990.
- Free from Harm, www.ihi.org
- Baker. Beyond the Quick Fix http://ihpme.utoronto.ca/2015/11/beyond-the-quick-fix/
- Attributed to P Drucker