Book Review

Patient Safety: Achieving a New Standard for Care

Accountability: Patient Safety and Policy Reform

N Engl J Med 2005; 353:322-324July 21, 2005

Article

Patient Safety: Achieving a New Standard for Care
(Quality Chasm Series.) Edited by Philip Aspden, Janet M. Corrigan, Julie Wolcott, and Shari M. Erickson. 528 pp. Washington, D.C., National Academies Press, 2004. $44.95. ISBN: 0-309-09077-6

Accountability: Patient Safety and Policy Reform
(Hastings Center Studies in Ethics.) Edited by Virginia A. Sharpe. 276 pp. Washington, D.C., Georgetown University Press, 2004. $49.95. ISBN: 1-58901-023-X

The belief that systems, more than individuals, are responsible for medical errors permeates current efforts to improve the quality of medical care and patient safety. Error reduction thus requires that systems be reformed, which necessitates far more information than is currently available. Patient Safety: Achieving a New Standard for Care articulates a vision of “a new health care delivery system . . . that both prevents errors and learns from them when they occur,” to be achieved through a national infrastructure of health information. The technical complexity alone that would be required to develop such an infrastructure would guarantee full employment for a generation of information-management technocrats and computer geeks. But the authors of Patient Safety foresee continuous, active use of the health information infrastructure to improve patient safety, and this would vastly expand the complexity of the undertaking.

A Nurse Uses a Handheld Scanner to Read a Bar Code on a Patient's Wrist before Giving Medication.

The use of a comprehensive, well-functioning information system to enhance the processes and outcomes of medical care also encompasses a human component, one that goes beyond sophisticated scientific and technological expertise. Patient Safety acknowledges those human factors, noting the need for cultural change if a new health care system that minimizes errors is to emerge. The essays in Accountability: Patient Safety and Policy Reform explore human and cultural elements in depth, offering thought-provoking commentaries on the rapidly burgeoning patient-safety movement. The goal of Accountability is “to analyze the values and ethical issues at stake in policy proposals on patient safety and the reduction of medical error.” At the least, cultural considerations span legal, ethical, philosophical, and psychological spheres, raising fundamental questions as to the appropriateness and achievability of improving both information systems and the quality of health care.

The two books share some heritage and subject matter, but little else. The genesis for each included the landmark Institute of Medicine report To Err Is Human: Building a Safer Health System (National Academies Press, 2000) and related publications, but these works go in different directions, which probably reflects their respective authorship. Patient Safety was produced by the Committee on Data Standards for Patient Safety and the Board on Health Care Services, both of the Institute of Medicine, whose members' expertise is predominantly in the fields of clinical care, informatics, and other forms of technology. The authors of the chapters in Accountability include relatives of persons harmed by medical errors, ethicists, lawyers, and health professionals.

Taken together, the two books provide contrasting perspectives on data-driven improvements in patient safety. Patient Safety is an exhaustive review of the extraordinary requirements of an infrastructure to improve care in our complex and incomplete assortment of health care delivery arrangements, and the book documents the laudable efforts of public agencies and the private sector to move in that direction. By showing us the extent of cultural adaptation that would be necessary, even if the technical components can be developed, Accountability forces the question of whether a visionary new health care system is a realistic goal or will remain no more than a vision toward which we should strive.

Patient Safety compiles and discusses the technical and operational requirements for the establishment of a national health information infrastructure and its use in the improvement of health care quality and safety. The current flow of health care information invokes an image of myriad isolated populations, each with different and incomplete knowledge bases, speaking different languages over incompatible cell phones. Patient Safety argues that improvements in care require data on virtually the full spectrum of health care components, which encompass nearly every step in every health care encounter, and more. Such information must be collected and maintained in systems that can talk to one another, with universally accepted standards in terms of format and terminology.

Furthermore, the actual improvement of patient safety requires that the wealth of information be used actively, for the ongoing reengineering of the health care system. The information must be linked to a series of computerized models and other measures that support the development and application of an enhanced evidence base for medical practice. The system must allow for the identification and analysis not only of adverse events that produce harm through errors of either commission or omission, but also of the larger universe of near misses, in which potential harm is averted.

Perhaps as an understatement of the remaining practical and technical impediments, the Patient Safety authoring committee asserts that the barriers that have prevented the implementation of “a health information infrastructure that supports learning and accountability systems for patient safety” are not primarily technological ones: “Rather, the lack of technology implementation and the failure to use common data standards have been the principal barriers.” The solution includes a fostering of leadership, the provision of financial incentives and technical assistance, and the enforcement of safeguards for privacy and security.

Accountability sheds light on where all this information would have to come from and why it is not currently available. The book begins with three stories of persons who suffered catastrophic harm from medical errors, as told by relatives who describe the consequences for the patients and their families. These narratives describe how errors were handled by health care providers — that they often involved defensive posturing, concealment, and insensitivity to the needs and feelings of both victims and survivors. The subsequent scholarly essays provide insight into these unfortunate responses to medical tragedies, discussing deep-seated human and cultural characteristics that may not easily be overcome. Although the authors accept that there is a need for systematic reforms, several of them raise the concern that the vast amount of information required to populate the new infrastructure might never be reported or generate the anticipated improvements in medical care.

A central tenet of the patient-safety movement, as reflected in Patient Safety, is that health care professionals and other health workers would behave differently and be willing to share information if the “blame and shame” character of our current system were replaced by a supportive, nonpunitive environment that rewarded the full reporting of adverse events and near misses. In Accountability, E. Haavi Morreim, a professor of human values and ethics, questions “whether the proposed protections for error-reporters will actually yield all the hoped-for information,” citing “ego, embarrassment, peer ostracism, loss of reputation, . . . skepticism that their reports will actually lead to useful change, or a desire to avoid the inconvenience of explaining what happened” as additional barriers to admitting mistakes. Physician and ethicist Edmund D. Pellegrino cautions us to recognize “the associated dangers of complacency and dulling of the moral sensibilities of the humans in the system when either a `blame-free' approach or a `blame-the-system' approach is adopted.” As a result, “the interaction of a system of error prevention with preservation of a sense of individual responsibility and culpability is essential.” Legal scholar and physician William M. Sage explores the complex role that reputation plays in physicians' behavior, concluding that “self-regulatory models that rely on professional peer review and informal sanctions to surface, analyze, and prevent error are inadequate substitutes for public surveillance and accountability.” Ethicist Nancy Berlinger reinforces the human facet, reminding us that the adverse consequences of medical error “happen to patients,” so that systems that promote “confession, repentance, and forgiveness” that are limited to the professional side of medical errors come up short by failing to ensure justice for patients.

Early on, the Patient Safety committee states, “Americans should be able to count on receiving health care that is safe.” In the last chapter of Accountability, Morreim argues that “probably the most important element in any system for addressing errors would be to ensure universal access to a reasonable level of health care for all citizens” and further asserts that differential access to insured care distorts the management of error and skews the compensation system. Morreim's statement suggests a paraphrase from Patient Safety: Americans should be able to count on receiving health care, and that will help ensure their care is safe. This should further caution us that we will come up short if we achieve a delivery system that minimizes error but serves only a portion of our population.

Peter P. Budetti, M.D., J.D.
University of Oklahoma College of Public Health, Oklahoma City, OK 73104
peter-budetti@ouhsc.edu

Citing Articles (1)

Citing Articles

1. 1

   Michael Saginur, Ian D. Graham, Alan J. Forster, Michel Boucher, George A. Wells. (2008) The uptake of technologies designed to influence medication safety in Canadian hospitals. Journal of Evaluation in Clinical Practice 14:1, 27-35
   CrossRef