René Amalberti, MD, PhD; Yves Auroy, MD; Don Berwick, MD, MPP; Paul Barach, MD, MPH
Acknowledgments: The authors thank Frank Davidoff, Jane Rossner, and Marshall Gilula for editorial review and helpful suggestions.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Paul Barach, MD, MPH, University of Miami Medical School, North Wing 109, 1611 Northwest 12th Avenue, Miami, FL 33136; e-mail, email@example.com.
Current Author Addresses: Dr. Amalberti: Département sciences cognitives, IMASSA, BP 73, 91223 Brétigny-sur-Orge, France.
Dr. Auroy: Hôpital Percy, Service d'Anesthésie-réanimation, 101 Avenue Henry Barbusse, 92141 Clamart Cedex, France.
Dr. Berwick: Institute for Healthcare Improvement, 20 University Road, 7th Floor, Cambridge, MA 02138.
Dr. Barach: University of Miami Medical School, North Wing 109, 1611 Northwest 12th Avenue, Miami, FL 33136.
Although debate continues over estimates of the amount of preventable medical harm that occurs in health care, there seems to be a consensus that health care is not as safe and reliable as it might be. It is often assumed that copying and adapting the success stories of nonmedical industries, such as civil aviation and nuclear power, will make medicine as safe as these industries. However, the solution is not that simple. This article explains why a benchmarking approach to safety in high-risk industries is needed to help translate lessons so that they are usable and long lasting in health care. The most important difference among industries lies not so much in the pertinent safety toolkit, which is similar for most industries, but in an industry's willingness to abandon historical and cultural precedents and beliefs that are linked to performance and autonomy, in a constant drive toward a culture of safety. Five successive systemic barriers currently prevent health care from becoming an ultrasafe industrial system: the need to limit the discretion of workers, the need to reduce worker autonomy, the need to make the transition from a craftsmanship mindset to that of equivalent actors, the need for system-level (senior leadership) arbitration to optimize safety strategies, and the need for simplification. Finally, health care must overcome 3 unique problems: a wide range of risk among medical specialties, difficulty in defining medical error, and various structural constraints (such as public demand, teaching role, and chronic shortage of staff). Without such a framework to guide development, ongoing efforts to improve safety by adopting the safety strategies of other industries may yield reduced dividends. Rapid progress is possible only if the health care industry is willing to address these structural constraints needed to overcome the 5 barriers to ultrasafe performance.
Average rate per exposure of catastrophes and associated deaths in various industries and human activities.
A strategic view of safety in health care.
Table. A Two-Tiered System of Medicine
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W. Harry Horner
May 4, 2005
Sixth System Barrier to Ultrasafe Healthcare
Over the past forty years organized medicine and many practitioners have been co-opted by third party payers through the grinding, day in and day out negotiation that goes on between medicine, business and government. Because the arrangements arrived at by this triumvirate have been made largely in secret, beyond the control of patients,and to their disadvantage, this relationship can accurately, and unfortunately, be described as the practice of medicine by conspiracy. This conspiracy has resulted in chronically inadequate (1) and inefficient (2) medical care and permitted the government, insurance companies, and corporations to dominate the practice of medicine with both frustrating and tragic results.
The relevance of this conspiracy, with regard to patient safety, is that individual physicians, nurses, and other health care workers who behave ethically, by reporting inadequate, unsafe patient care, may find themselves not only ignored, but retaliated against (3,4), rather than being positively acknowledged for their professionalism and patient advocacy.
Such unethical and inappropriate attacks against physicians "“ and obstruction of improvements in patient care - are made possible by other physicians who initiate or co-operate "“ either actively or passively - with retaliation for a variety of reasons. They may see targeted physicians as competitors; or seek to gain favor with regulators and/or financiers; i.e. power; or they may simply identify with the aggressor in an understandable, but misguided, attempt to avoid the fate of the targeted physcian. In any case, successful retaliation of this sort against one staff member sends a clear message to others that it is not in their best interest to voice concerns regarding issues such as inadequate training, supervision, staffing, equipment, medications, etc.
I suggest that professional ethics are a sixth and major barrier to ultrasafe healthcare. Unfortunately, it is clear that individual sacrifice on the altar of patient safety is not enough (3). Organized medicine must make it clear through actions, as well as words, to its members, hospitals, and lawmakers, that patient advocacy is a professional responsibility and that retaliation against professionals who speak out ("Profession" comes from the Latin "speaking forth"), in order to prevent patient injury and assure adequate care, will not be tolerated. Until that happens patient safety will continue to be merely an aspiration. No matter how well designed, a system "“ any system "“ is, ultimately it is only as good as its operators.
1. Mathes CD, Sadena R, Salomon JA, Murray CJL, Lopez AD. Healthy life expectancy in 191 countries, 1999. Lancet 2001 357:1658-1691.
2. Evans DB, Tandon A, Murray CJL, Lauer JA. The comparative efficiency of national health systems in producing health: an analysis of 191 countries. GPE Discussion Paper Series: No. 29. WHO. 2000.
3. Twedt S. The cost of courage: How the tables turn on doctors. Pittsburgh Post Gazette. Oct. 26-29, 2003. http://www.post- gazette.com/pg/03299/234499.stm. Checked 5/3/05.
4 Plantz SH, Kreplick LW, Panacek EA, Mehta T, Adler J, McNamara RM. A national survey of board-certified emergency physicians: quality of care and practice structure issues. Am J Emerg Med 1998;16:1-4.
Lucius F Wright
The Jackson Clinic, P. A., Jackson, Tenn., 38301
Amalberti and colleagues' thoughtful analysis of cultural barriers to maximizing patient safety in healthcare is provocative. I was struck by the similarities to the issues I have encountered in dealing with purchasers of healthcare services. I think we are fundamentally split. When we are not too sick, we want a safe system, do not particularly care about the identity of the provider, and want the service provided as a commodity, just as we expect Wal-Mart to deliver everyday low prices, on demand availability, and guaranteed results. On the other hand, if we are really sick, and think there is a good chance we might die, then we want "the best," however defined, and cost is no object. I call this the Nieman-Marcus approach to health care.
Clearly this schizophrenia causes problems for physicians and consumers, formerly known as patients. A physician who decides his/her service is an interchangeable commodity, one of the first goals for attaining a culture of safety identified by this article, he/she is unlikely to exert him or herself to be Marcus Welby, M. D., on call all the time, with infinite time and patience to spend on one patient. Good old Marcus, though, is likely to be labeled "unsafe," because he clearly took his craftsman's role seriously.
The authors note that airline safety processes may not be fully interchangeable with the healthcare system. We all agree that catastrophic loss of an airplane is worth trying to avoid, but in healthcare we confront the fact that we are going to lose the patient, albeit hopefully one at a time. This is not an argument against trying to improve our safety record, rather it is a plea to recognize that unavoidable deaths are sometimes hard to separate from the inevitable deaths.
The authors suggest that safety goals need to be "tiered." I agree. If the parallel with the service demands of our patients and purchasers is correct, then I suggest as much as 70% of the care is, in fact, a commodity. We can, therefore, construct a workforce and a care delivery system to meet the "on-demand" needs of patients at low prices, with a 10- 6 safety level. 20% of the care is high intensity, but short term, care traditionally associated with hospitals. Perhaps we should settle for a 10-3 or 10-4 level of safety here. The other 10% is the complex chronic care, which constitutes a good part of the outpatient care for many internists and medical specialists. In many of these cases, we need a surrogate for death as a safety measure, since the death of the patient is assured.
I am not optimistic, though, that we as a society can conduct a meaningful dialog on what we want from our healthcare system, how much we are willing to spend on it, and how safe we want it to be. Perhaps the authors' next paper could focus on the barriers to safety that reflect our cultural preferences, our dietary habits, and our persistent belief in magic potions.
René Amalberti, Yves Auroy, Don Berwick, Paul Barach. Five System Barriers to Achieving Ultrasafe Health Care. Ann Intern Med. 2005;142:756–764. doi: 10.7326/0003-4819-142-9-200505030-00012
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Published: Ann Intern Med. 2005;142(9):756-764.
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