Safety at what cost?

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