The father of patient safety

You’ve had a distinguished surgical career. Why did you decide to move into health policy research?

Academic surgery was leading me to become burned out. I was having fewer good ideas and was tired of the rat race. I had trouble quitting because I love surgery and taking care of children, who are the world’s best patients.

However, it seemed that things were worsening at policy level and that economists were making the decisions in healthcare. I thought that physicians should quit complaining, roll up our sleeves, and get to work. In the practice of medicine, you save lives one by one, but in public health you save them by the thousand, so in the policy world you can have a greater impact. I love surgery and taking care of patients and I love what I’m doing now. They’re satisfying in different ways.

You’re often described as a medical leader. What does that term mean to you?

Most of all it means “first one in.” I wrote a paper called Error in Medicine in 1994 and there were no papers on the subject before that because nobody wanted to talk about it. This became the impetus for the Institute of Medicine to publish To Err is Human,2 announcing that up to 98 000 people in the US were dying from medical errors. The television stations thought this was newsworthy, but fortunately they and the president got the important message from the Institute of Medicine that errors are not because of bad people, but because of faulty systems. This concept, that to reduce injury rates in healthcare we have to redesign our systems, has led to an international patient safety movement.

How much progress has the patient safety movement made?

We’ve certainly made a lot of progress, but not nearly enough or fast enough. The challenge of changing systems is much bigger than we first recognised. Doctors are conservative and we’re trying to change the culture in a system that is rife with tradition and belief in physicians’ autonomy. Modern healthcare is the most complex human activity there is, due to interpersonal relationships between many different clinicians with different expertise and interests, and we haven’t figured out how to make that work well. We have come to a full stop against a complex environment that resists accepting change on the scale clearly required.

Is there anything you would have done differently?

That’s hard to know. As a research team we could have been more astute and prepared better for the extent and complexity of the culture change we were trying to make. I don’t think we did anything wrong, but when the research regarding the prevalence of error was published there were a lot of angry physicians. They thought we were wrong and resented us because they thought our research made medicine look bad. I look upon that as an inevitable part of change, and it passed. Despite this, it’s been rewarding to see that people are taking on the issue of medical error and preventable injury now.

What is the role of technology in reducing medical error?

Organisations that have succeeded in making substantial improvements in quality and safety all have efficient information technology in terms of data collection, electronic medical records, and computerised physician order entry systems. Information technology is absolutely critical to moving ahead in safety but it’s just a tool, a facilitator; you still have to optimise and redesign processes.

One other use of information technology is teaching by simulation. Simulation is very effective at helping people deal with difficult situations such as crises in the operating or emergency room, disclosing medical error to patients, and teamwork. Everything I’ve seen is positive, and many of us believe it will become more and more woven into everyday medical practice and teaching.

What advice can you give to students aspiring to be involved with health policy?

We’re always looking for people with an interest in making things better. Quality improvement ought to be part of everything we do; physicians should not only think about doing a good job but about how they can do it better.

For those interested in pursuing policy, quality, or safety I think having a strong clinical background is important. Quality improvement is about behaviour change. You’re trying to get people to do their work differently and they’re more likely to listen if they respect your background and experience.

There are opportunities to be involved 5%, 50%, or 100% of the time; there’s room for all kinds improvement and you’re limited only by your own imagination and interests. It is also important to remember that being a doctor is a privilege and physicians ought to be humble. Every day physicians can look forward to making a difference in somebody’s life, and that’s something which should make you happy.