Safety First – NOT!

There is a recent push in U.S. hospitals to inculcate a “culture of safety.” Can anyone be against safety? I can and you will be too, if you want healthcare to improve.

Safety refers to eliminating accidents, mistakes and errors that lead to injury. The first line in our defense is supposed to be the regulations. Presumably, they are intended to protect us but most do the opposite. They assure compliance not safety and waste huge sums of money.

Healthcare can learn a great deal from industries such as airplane and auto manufacturing. Business has learned to create systems with prevention of mistakes and accidents built in. Examples include: online system checks; black belts; event trees; simulations; a host of dreaded “TLAs” – three- (or four-) letter abbreviations – such as BFM, CAPA, CQM, CQE, CRM and FMEA; as well as Poka-yokes, KanBans and Jidoka. Some – but too few – have been applied to healthcare and often unmodified, which is a big mistake.

In creating a “culture of safety,” you need to ask safety for whom: the patient, the doctor or the hospital? Sometimes, the safest course for the doctor medico-legally is not the best course medically for the patient. When a lawsuit is filed, the safest course for the hospital is often not in the best course either for the doctor or the patient.

Most important, safety must not be our highest priority, not if we want quality. Medicine is critically different from other businesses or sciences in this: absolute answers are not known and individual outcomes are not predictable. That lack of knowledge leads to bad outcomes, without anyone ever making a mistake. Medicine simply does not have treatments that work every time for every person with no side effects or complications in: cancer, arthritis, diabetes, asthma, delivering a baby, hernia repair, even pneumonia. Medical care involves risk by definition.

If we patients want better quality outcomes, than we must: a) accept that medical care inherently carries risk, and b) encourage healthcare to accept risk in order to learn. Only by learning can they improve our outcomes AND reduce the inherent risk. This is a different sort of risk but risk nonetheless.

What do you want: medicinal poisons or a real cure for breast cancer; treating sickle cell disease or deleting the defective gene; sedating the patients with Parkinson’s or eliminating the disease? If the latter(s) are your choice, then you want safety second and learning (risk) first.

I do not disparage safety initiatives, quite the opposite, I support them: as long as they do not make healthcare even more defensive and totally risk-averse.

If we want better quality medical outcomes, we need to place learning first and safety a close second.

System MD

Reply:

A Commenter asked for examples of what I mean by systemic safety. First two easy, “quickies.” (1) A pre-procedure checklist for any procedure from putting in an IV to brain surgery. This shouldn’t be optional or hospital-specific. It should be a standard systematic approach. (2) The couplings between ventilation machines and the gases or liquids that you put in should be specific to that gas or liquid. It should simply be impossible to infuse nitrogen when you mean to give oxygen.

Most quality improvement programs are more focused on following regs than preventing bad outcomes. HIPAA and other rules actually prevent information sharing. When I told a colleague in NASA about how we handled (Ostrich approach) bad outcomes, he was aghast. He yelled, “Hell, whether it is United or American or the military, we all share information on near-misses and collisions so we ALL can learn.”

Simply, we should have people who go around and either investigate what did go wrong or imagine what could go wrong. They then work up preventative scenarios and make recommendations for system-wide safety precautions. These people should NOT be regulators or JCAHO employees, but real world nurses and doctors.

System MD

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