Time USA - 25.11.2019

26 Time November 25, 2019

Official and popular reaction to the 1999
paper was swift. Congress mandated the mon-
itoring of progress in efforts to prevent patient
harm, and the health care industry aspired to
grand goals, like the report’s recommendation
of reducing medical errors by 50% within five
years. News outlets tracked the proceedings
closely. A remedy for a long-standing problem
seemed in sight.
But a September 2019 report on patient
safety from the World Health Organization
found not much has changed. Globally, medi-
cal errors harm as many as 40%
of patients in primary and outpa-
tient care. Diagnostic and medi-
cation errors hurt millions and
cost billions of dollars every year.
So what happened? The chain
reaction to the 1999 report spent
its energy quickly. Contrary to
the report’s calls for expertise
from outside the medical profes-
sion, patient safety was taken
over by clinician managers and
other health care administrators
whose interests would hardly
have been served by a thorough,
pardigm-shifting investigation of
the crisis that would have rattled
the status quo. These institu-
tional leaders also brushed off ex-
perts (psychologists, sociologists
and organizational behaviorists,
among others) who have long of-
fered innovative ideas for reduc-
ing health care mishaps.
The medical managers had
ideas too, but those amounted
to localized—and weak—
prescriptions like safety check-
lists, hand- sanitizing stations,
posters promoting “a culture of
safety,” and programs inviting low-level staff
members to speak their minds to their su-
pervisors. Absent were innovations aimed at
bigger classes of hazards such as look-alike,
sound- alike drugs (mix-ups in the medica-
tions epinephrine and ephedrine have led to
much patient harm, for example) or confusing
and error- inducing interfaces in technology
(when simple technology for connecting de-
vices fits multiple tubes, outlets or machines,
increasing the possibility of misconnections).
Patient safety can be tricky to define, be-
cause it’s essentially a nonevent. When things
are going well, no one wonders why. When a
mistake occurs and threatens the unrealistic
“getting to zero” goal of many health care

managers, then it becomes an event that de-

mands a reaction. And the reaction generally

is to assign blame to people further down the

organizational ladder.

It’s far easier, after all, for the industry to

fault individual workers on the front lines of

medical care than to scrutinize inherent orga-

nization and system flaws or to finger highly

paid specialist doctors. This focus on who did

wrong and how they did wrong is misplaced. It

should be on what’s going right and what les-

sons can be learned from successes.

This is how health care organiza-

tions and the industry as a whole

avoid dealing with the troubling

task of identifying root causes of

the patient- safety problem. Mean-

while, the public is assured there is

little to fear (and little need for ex-

ternal intervention) because, after

all, health care professionals are on

the job. But clinician leaders and

hospital administrators need to

realize that health care, including

its patient- safety component, is too

big and too complex to be steered

only by medical professionals. We

live in an era of multi faceted prob-

lems that call for multi disciplinary

approaches. Advances in anesthesia

safety, for example, would not have

come without the input of engi-

neers. Experts from outside medi-

cine should be welcomed to any se-

rious discussion of how to improve

patient safety, and their insights

heeded.

Let the words of John Send-

ers, a pioneer of human- factors

engineering, help guide a truly re-

formed patient- safety movement:

“Human error in medicine, and the adverse

events that may follow, are problems of psy-

chology and engineering, not of medicine.” An

important social movement seemed to emerge

in the wake of “To Err Is Human” but lost its

way. With bolder and more comprehensive

goals, and by embracing experts from outside

the medical profession, the health care indus-

try could make patient safety the great social

movement it deserves to be.

Sutcliffe is a professor of business and medicine

at Johns Hopkins University and a co-author of

Still Not Safe: Patient Safety and the Middle-

Managing of American Medicine ( forthcoming

from Oxford University Press)

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SHORT

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▶ Highlights

from stories on

time.com/ideas

The fight for

Dreamers

In 2017 the Trump

Administration said

it would end the

Deferred Action for

Childhood Arrivals

(DACA) program. With

the case now before

the Supreme Court,

Microsoft president

Brad Smith and

Princeton president

Christopher L.

Eisgruber write that

“standing up for DACA

students is not only

the right thing to do

morally, it is also

the right thing to do

competitively.”

Breaking bad

habits

We have to stop wast-

ing so much food,

write Bishop Marcelo

Sánchez Sorondo,

chancellor of the

Pontifical Academy of

Sciences, and Michael

Shank, communica-

tions director of Carbon

Neutral Cities Alliance.

One solution: “Let’s

eat more ugly fruits

and vegetables.”

A path for

protesters

A new Arab Spring

is unfolding in Iraq

and Lebanon, writes

University of Waterloo

professor Bessma

Momani, but the

demonstrators must

learn from past failures

in the region. Protests

“could also prove to be

bloodier if Iran gets its

way,” she warns.

40%

Share of global primary-

and outpatient-care

patients harmed by

medical error

$42

BILLION

Global annual

cost of

medication-related

errors

1

MILLION

Patients, globally,

who die every year

from surgical

complications