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PEER REVIEW: PATIENT SAFETY
Why is Healthcare Still not Safe? Written by Dr Dale Whelehan, PhD in Behaviour Sciences, Trinity College Dublin, the University of Dublin
In the turn of the century a report was published recognising ‘to err is human’. It recognised the fallible nature of humans, and how error-making is a part of work. Nonetheless, ongoing discussions exist in the media and literature as to ‘why is healthcare still not safe?’. In this article, I will give an executive overview, based on empirical evidence and broad disciplinary considerations, that such issues exist to a myriad of intertwining complex and historically associated variables. There will be reference to the foundations of the safety for patients movement, the growing influence of medical bureaucracy, the flaws in research design and assessment of progress, and an overemphasis on leveraging change at the individual level and not the organisational level. Foundations of patient safety First – we need to look back to fully understand the causal factors which led to the formation of focus on healthcare safety. While this article questions why healthcare is still not safe, and could be argued from the lens of injury to practitioners in their work, the focus of this article is on the end user of healthcare work – the patient. Patient Safety is a healthcare discipline that emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities. As a discipline it aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care. A cornerstone of the discipline is continuous improvement based on learning from errors and adverse events.
Day to day adverse events create a burden of harm which can lead to safety issues for our patients. These include things such as medication errors, diagnostic errors and health-care associated infections. The issue of patient safety was first raised in 1847 by Semmelweiss who documented the difference in rates of medical harm across two wards of care. Coupled with disparate amounts of research over the coming decades, a seminal study conducted by Moser in the 1960’s called ‘Diseases of Medical Progress’ as well as the Harvard medical practice study first began to succinctly identify instances of safety concern in healthcare. This was the beginning of the research movement and founded with input from the safety sciences. A successful application of this research, and considered a gold standard example to this day, was the application of human factors and safety science research to the discipline of Anaesthesia by a researcher called Jeff Cooper. Large scale reductions in patient harm were recorded from this initial movement. Alongside this stream of work, a parallel movement was forming, motivated by milestone cases relating to medical error. Confounded by several variables, including media, these cases created a political uproar as each played on a different public fear. Libby Zion, who died as a result of poor supervision and overworked staff. Willie King, whose wrong leg was amputated. Josie King, who went to a prestigious and highly rated hospital for cancer treatment and received a dose that was too high. Elaine Bromley, who went in for a routine nasal operation and died soon after. Growing hostility towards the healthcare
AUGUST 2022 • HPN | HOSPITALPROFESSIONALNEWS.IE
professions ensued, with large blame being placed on individuals within systems. There was a true desire to prevent such cases from ever happening again, leading to successful events such as the Annenberg 1 and 2 conferences. These brought together a broad range of stakeholders under the impetus to make healthcare safe in the turn of the century. A third movement emerged around this time, fuelled in part by both aforementioned movements, but also by publication of significant reports such as the ‘To Err is Human’ report which estimated 44,000-98,000 deaths/year U.S citizens died due to medical error every year. Political will to deal with these issues through ‘shaking up healthcare’ resulted, leading to application of managerialism style interventions. Medical practitioners became managers to deal with issues of safety, leading to the formation of an in-group thinktank for patient safety assurance. Industralisation of medicine ensued, creating a corporate elite of healthcare staff who utilized superficial principles of evidencebased approaches from the safety sciences, in conjunction with Taylorism principles of scientific management, to create faux solutions which were branded as scientific interventions. This has become the dominant movement, and despite efforts, a 2016 John Hopkins Study concluded that little progress has been made and safety issues are the 3rd leading cause of death. Research design A discourse has been ongoing in academic institutions since the biomedicalisation of patient safety research. A twenty year review has found that, using retrospective analysis of charts, there exists little shifts in the metrics previously used to define safety in healthcare – whether they be harm, adverse events, or medical error. The interchanging utilisation of these terms has meant the research is heterogenous, and often poorly understood. Utilisation of inappropriate research methods to make sweeping generalisation and conclusions has become a normal issue in the discipline of research, further conflating the
difficulty in truly understanding the effective interventions to make healthcare safer. Along the journey since the publication of To Err is Human, we have lost one of the pivotal segments of the research puzzle – to involve the experts of safety sciences – the psychologists, anthropologists, human factor engineers – as our methodological experts. Instead we have biomedicalised the discipline, broadening its parameters to include aligned disciplines such as infection control, which has led to a forever squeezing of opportunity for the nonepidemiological disciplines. This positivist approach has meant many disciplines have been effectively silenced. A fundamental realignment to recognise that medicine needs these disciplines to make evidence-based interventions is important. Organisational behaviourist Dr. Kathleen Sutcliffe has conducted extensive research on the issue of healthcare safety and concludes healthcare is a mindless and vulnerable system. She identifies a series of confounding variables influencing healthcare issues – ranging from micro-issues such as individual performance, mezzo issues such as interpersonal skills, as macro issues such as organisation design and culture. These manifested themselves through behaviours which led to individualism, siloed ways of working, hierarchical governance, and inability to meet growing public service needs. The growing focus on performance science in recent decades from psychologists has also identified a link between staff wellbeing and patient safety. While healthcare workers have always worked above and beyond their vocational requirements, the confounding role that COVID has played on levels of burnout in the healthcare workforce is likely to significantly influence healthcare safety efforts. Culture One of the growing issues around patient safety is the risk of poor patient safety culture. When individuals work together, in teams, and not just groups with individuals with personal
