Promoting patient safety, preventing medical error, preventing physician error, preventing errors in diagnosis, preventing nurse error, preventing surgical error, preventing communication error, preventing health illiteracy error, preventing errors from language barriers, preventing laboratory error, preventing computer error, preventing patient mix-ups, preventing right and left side of body mix-ups, preventing mistakes, since mistakes are the stepping stones to failure.
Recognizing human frailty, recognizing physician humanity, recognizing system fallibility, owning up to problems, eliminating cover-up, acting out professionalism, recognizing that professionalism means self governance, individually and as groups.
Self criticism, peer criticism, a culture of peer review, honesty, truth, disclosure, fairness, and negotiated settlements.
Objective evaluation and commitment to quality. Quality improvement by preventing error. Systematic error, systematic prevention of error. An error caught before an action is taken based upon that error is, in effect, not an error.
These are the fundamental truths that the patient safety movement is all about.
A system is a regularly interacting or interdependent group of items forming a unified whole, a group of interactive bodies under the influence of related forces. Every organized effort is a subsystem within a set of interactive systems. Systems must include purpose, direction, plans, goals, and feedback loops. In theory, every loop should be closed.
Since the patient safety movement burst upon the scene some 20 years ago, the literature representing the body of work about patient safety has burgeoned. Academic knowledge has ballooned.
However, sad to say, improvement in documented actual patient safety has lagged grotesquely. Part of that retardation can be blamed upon a continuing culture of cover-up.
Since it is the safety of patients and not the management of risks for the medical system and its players that this is all about, I am heartened by the recently reported proposal that a regular system be established to encourage patients to report adverse events, said to affect 25% of all hospitalized patients.
This is one more process piece that could help begin to turn this large, recalcitrant, omnipresent problem around.
George Lundberg is a MedPage Today Editor-at-Large and former editor of the Journal of the American Medical Association.
