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EDITOR'S CHOICE: Douglas Kamerow Safety at what cost? BMJ 2007; 334: 0-a [Full text]

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Patient Safety: No easy solutions without system redesign

Daniel Longo   (15 January 2007)

Patient Safety: No easy solutions without system redesign 15 January 2007
Daniel Longo, Professor of Family Medicine University of Missouri-Columbia, School of Medicine, Columbia, Missouri 65212 USA Send response to journal: Re: Patient Safety: No easy solutions without system redesign	The articles in this issue point to the on-going problem of patient safety; these concerns are not limited to the countries where these studies have been conducted. It is an international problem and for decades has been hidden under the many masks of peer review, confidentiality, risks of hospital care, as well as care in all health care settings. We are well into the 5th year since the United States' Institute of Medicine's (IOM 2001) landmark reports on patient safety and medical errors. A variety of studies have documented that there has been some progress but that the progress has been slow and not in proportion to the gravity of the problem. The IOM reported “serious and widespread problems occur in small and large communities alike, in all parts of the country,” (Chassin, 1998; IOM 2001) and called for “fundamental change…to close the quality gap and save lives.” The problem is that despite all of this attention and the many efforts in the United States as well as the United Kingdom and other parts of the world the problem still exists.(Leape 2005, AHRQ 2004)The reason: we need to be honest --- there has not been fundamental change; business as usual is the story in most hospitals. System change in hospitals has been slow (Altman 2004; Wachter 2005; Longo 2006) and there are many interest groups that resist change. This statement is neither one that is well received nor one that is seriously acted upon. Further, a review of curriculum of medical schools, nursing schools and other schools where health professionals are trained, at least in the United States, show only token attention to the inclusion of issues related to quality of care, the process and systems of care, system change and reform. Rather, one may hear more about pay for performance and other ways to maximize hospital and physician reimbursement. While the later are clearly important concerns, something is clearly wrong in the priorities of medical and health care education and delivery. Quality of care must be put as the top agenda item of all involved in this complex system. Most, physicians and health care professionals enter the profession for good and noble reasons. But, as time passes it is easy to not rock the boat and not join the quality reform movement. One must note that there are a number of excellent innovations underway, but again change is slow; until the very fabric of the medical education system as well as the healthcare delivery system acknowledges the extent of its problem things will remain the same. Reform is not easy and most reformers are never, as the same expression is applied to profits, "heard to in their own land." So, conferences are filled and consultants are called in; but the basic system remains the same. Let us face the fact, that until there is a real public out-cry for health care reform based on concerns of quality rather than cost alone, it will be business as usual in most health care organizations. There is an old French expression, "the more things change the more they remain the same." This appears to apply the health care system in most of the western world. In the 1800's in her famous "Notes on Nursing", Florence Nightingale stressed that "the very first requirement of a hospital is that it do a patient no harm." So, the beat goes on and the problem remains. We need not just reform but a real revolution. Perhaps for a while the medical and health care professions still have a chance to reform from within; however, if this does not occur the public will eventually stand up and revolt. Then changes will come from outside the system rather than from within and the results may cause many health care providers to retreat from the shelter of peer-review and confidentiality. Perhaps then we will have left about quality and ride out the current tide; those who really care those who will make a difference by challenges existing systems and making the reforms in the basic systems and processes of care that must be examined and changed. In the end the problem is not bad providers but systems that do not safeguard quality; if there is a human problem it is found among those who few individuals who control the system who are unwilling or unable to see the that problem is wide-spread and in their own back yard. That is the critical human problem --- failure to accept reality and the responsibility to change. References: Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. JAMA 1998; 280(11):1000-1005. Committee on Quality Health Care in America, Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, D.C.: National Academy Press; 2001. Leape LL, Berwick DM. Five years after To Err Is Human: what have we learned? JAMA 2005; 293(19):2384-2390. Wachter RM. The end of the beginning: patient safety five years after 'To Err Is Human'. Health Aff 2004; 24(1):W4-534-W4-545. 2004 National healthcare quality report. Rockville, MD: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services; 2004. Altman DE, Clancy C, Blendon RJ. Improving patient safety--five years after the IOM report. N Engl J Med 2004; 351(20):2041-2043. Galvin RS, Delbanco S, Milstein A, Belden G. Has the leapfrog group had an impact on the health care market? Health Aff (Millwood ) 2005; 24(1):228-233. Agency for Healthcare Research and Quality. 2005 National healthcare quality report. Rockville, MD: U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality; 2005. Longo DR, Hewett JE, Ge B, Schubert SL. The long road to patient safety: a status report on patient safety systems. Journal of the American Medical Association, December 14, 2005; 294(22):2858-2865. Competing interests: None declared