You would be hard pressed to find someone more qualified to discuss patient safety than James Bagian, MD, PE. Dr. Bagian is director of the Center for Healthcare Engineering and Patient Safety and a professor in the medical school and the college of engineering at the University of Michigan in Ann Arbor, is a former NASA astronaut, served as the chief flight surgeon and medical consultant for the Columbia Accident Investigation Board, and supervised the recovery of the Space Shuttle Challenger.
Dr. Bagian gave the Joseph H. Ogura Annual Lecture at this year’s Triological Society Annual Meeting. He opened his talk with a question he has been asking for 20 years: “If you found Aladdin’s lamp and were allowed to make a wish for patient safety, what would you ask for? A) that nobody in your institution would make any errors in the next year, or B) that no patient in your institution would be harmed.” Nearly the entire audience answered “B.” Dr. Bagian noted that, until 2003, “we routinely got the opposite answer.”
The overarching goal should be to prevent inadvertent harm to patients, he said, adding that physicians are best positioned to do this if they have a thorough understanding of what makes a healthcare system work well. “There tends to be a lack of systems understanding,” he said. “To put a fine point on it, what would the patient want? They care that they don’t get harmed.”
Planning Prevents Tragedies
Dr. Bagian suggested a look at the airline industry. “If you think no errors occur in airplanes, then that is a fantasy,” he said. “What saves us is the checks and balances that are in place to assure that the plane ultimately arrives safely. The idea is to design a system such that, even when things do go wrong, there is an efficient way to make corrections or that the system is robust in its design so that individual component failures do not result in catastrophic outcomes.”
“In healthcare, we have a cottage industry type of mentality [that is] reminiscent of a guild system of apprenticeship; I call it ‘eminence-based medicine,’” he said. “The common refrain is, ‘Well, this is how we do it here.’” He also noted that, when physicians gather, they inevitably ask each other, “Where did you train?” He said that if patient care were uniform, then it wouldn’t matter. “When engineers meet up, they don’t ask where someone trained, because the principles that they deal with every day, such as Bernoulli’s Principle, are the same no matter where you trained.”
The idea is to design a system such that, even when things do go wrong, there is an efficient way to make corrections or that the system is robust in its design so that individual component failures do not result in catastrophic outcomes. —James Bagian, MD, PE
Fault Finding Has Supplanted Actual Change
“There has been too much ‘train and blame’ in healthcare,” Dr. Bagian said. A typical approach to a mistake is to institute new policies and/or reporting systems and put someone through training, he added. “While policies and training may be necessary, they are not sufficient by themselves and won’t correct the problem if only used in isolation. These are superficial solutions.” When people make a mistake, he said, they are typically told to be more careful or to try harder. He said this is a lost opportunity to take a hard look at what happened on a systems level and implement effective systems-based countermeasures.
He also said that physicians need to take a much closer look at mistakes that almost happen. By studying close calls, the aviation industry has prevented untold number of accidents and misery; unfortunately, very few health systems in the United States accept reports of close calls, and even fewer use the close call reports that they do receive to identify patient safety vulnerabilities in their institutions and take corrective actions to prevent harm to their patients, he said. “Instead, they appear to subscribe to the ‘no harm, no foul’ philosophy, which is antithetical to any organization that truly understands safety and what it takes to become a high reliability organization,” he added.
“We must focus on changing the culture in our institutions,” Dr. Bagian concluded. He recommended forgetting about asking whose fault something is, and instead ask what happened, why did it happen, and what do we do to prevent it in the future. “We should be focused on system-level causation,” he said. “Having a stronger preventive strategy is more likely to get us to a place of sustainable change and improved care for our patients.”
Elizabeth Hofheinz is a freelance medical writer based in Louisiana.