Intended for healthcare professionals

Rapid response to:


Medical error—the third leading cause of death in the US

BMJ 2016; 353 doi: (Published 03 May 2016) Cite this as: BMJ 2016;353:i2139

Rapid Response:

Re: Medical error—the third leading cause of death in the US: Cultural Complacency and Patient Safety

Cultural Complacency and Patient Safety

The recent paper by Makary and Daniel once again confirms the magnitude of the crisis in patient safety that is confronting both healthcare professionals and patients1. By any measure, interacting with the healthcare system, i.e., receiving healthcare services, is potentially dangerous for one’s health. In the USA estimates of 250,000 deaths per year are now confirmed. Five American baseball stadiums of mothers, fathers, grandparents, children, other relatives and friends – will die as a result of healthcare, and many orders of magnitude more will be harmed. This is truly a national public health disaster and similar data from other countries serves to define this as an international public health catastrophe. How can this be?

Though there have been some notable improvements over the past 25 years since publication of the US Institute of Medicine’s Report, To Err is Human2, particularly improvements in healthcare associated infection prevention and control, and through the utilization of standardized processes and procedures in the performance of invasive procedures, the management of indwelling catheters and ventilator management; the fact is that major broader-brush improvements in mortality and morbidity have not really been realized. Yes, thousands of lives have been saved and harm avoided but far, far too many are still dying or being injured as a result of healthcare. Why, is the question.

I have been a physician for forty-five years, as a clinician, a healthcare executive and now as a consultant in patient safety. In my view, the solutions to improving patient safety lie in identification of the innumerable contributing factors resulting in causality through a root cause analysis. I suspect that what we will find is that the underlying malady of our healthcare system is a highly predictable, catastrophic cultural complacency that is deeply pernicious throughout our systems of care. The fact is that failures in leadership, culture - which is the responsibility of leadership – structures, processes and also personal performance can all be traced back to some elements of complacency and the contributing factors that contribute to complacency.

Leaders are not consistently promulgating cultures of safety and justice and are not consistently providing structures and embedding processes focused on safety or providing support for front-line staff. Clinicians, at the tips of the spears or perhaps tips of scalpels and needles, don’t see themselves as being dangerous and, when working within systems that are not fully resourced and supportive of work efforts, are likely to fail. When we are overworked and stressed we do not experience joy and meaning, so necessary to personal and professional wellbeing, and this can also feed complacency. The bottom line seems to be that we just don’t acknowledge how inefficient and dangerous many of our systems and processes are, and many clinicians fail to recognize or consider how unsafe they also can be.

Clinicians are benevolent in their intentions, and many of us never envision that we might actually harm patients. Yet, our processes of diagnosis and communication are terribly flawed, encumbered by numerous human factor weaknesses and biases that many of us may not even be aware of. Cultural complacency can become malevolent under such circumstances.

A simple example of this is the hand-washing conundrum. We do not consistently wash our hands before and after examining patients and the reasons for this have recently been examined3,4. All clinicians know that we can be sources of transmission of dangerous pathogens, but we also know that the likelihood that one particular patient examination will result in a serious infection is remote at best. Thus, in our busy workday, dealing with multiple patients under varying circumstances, and subject to innumerable workplace stressors and distractors, we have normalized this deviation in the standard of care. We do not wash our hands because subconsciously we know the risks are minimal. Unfortunately, some patients will become infected. Extending this example more broadly, numerous other processes of health care grow out of kilter when complacency reigns, when we fail to recognize how dangerous we can be and when we normalize deviation.

So, how do we begin to deal with this is the real issue. How do we overcome the pernicious complacency that affects our healthcare systems from top to bottom? We need to confront this public health crisis as we would any other. We must stop blaming individuals when they make mistakes or when they normalize deviation because it is a human quality to make mistakes and to normalize deviation. We all do it. We need to train a generation of leaders, managers and clinicians who understand the parameters of providing safe healthcare and who, working together, may design and structures and processes for success in a higher-reliability context. But, most importantly we must at first recognize and admit that our own complacency, and our own tendencies to normalize deviation are substantial contributing factors to causality. We are all ultimately responsible and accountable, though many factors we may not recognize contribute to our actions and inactions. Faults lie somewhere in the complexities of all of this, and personal blame has no role to play in improving safety.

Perhaps as leaders, managers and clinicians we need to begin our days by walking into our hospitals, by pausing at the front doors and saying to ourselves “I am dangerous, I don’t mean to be, but I am and I really need to think about what I do and how I do it. Out of respect for patients that I am honored and privileged to care for, I must recognize and overcome my personal liabilities and those of the systems of care I work in and the processes I work with. I must put distractions aside and focus on what is best and safe. That is my ethical obligation.”

Daniel L Cohen MD, FRCPCH, FAAP
Chief Medical Officer
Datix Ltd (UK) and Datix Inc (USA)

1. Makary MA, Daniel M. Medical Error - the third leading cause of death in the US. BMJ 2016;353:i2139 doi: 10.1136/bmj.i2139 (Published 3 May 2016).
2. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system, National Academies Press, 1999.
3. Redelmeier DA, Shafir E. Why even good physicians do not wash their hands. BMJ Qual Saf 2015;24:744–7.
4. Cohen DL. Hand washing is all about respect for patients. BMJ Qual Saf (Published on line first, 19 April 2016] doi:10.1136/bmjqs-2016-005538.

Competing interests: No competing interests

09 May 2016
Daniel L Cohen
Executive physician consultant in patient safety
Datix Ltd (UK) and Datix Inc (USA)
Melbury House, 51 Wimbledon Hill Road, London SW19 7QW