Preventing harm from healthcare - where are we?

I'm reading Sorrel King's book "Josie's Story" about her beautiful little girl - less than two years old - who died at Johns Hopkins several years ago as the result of avoidable errors in her care.  This is a story that I have heard many times, including Ms. King's own account from the podium at large meetings such as those of the National Patient Safety Foundation. She has been a tireless advocate for patients and for making healthcare safer, a reminder to all of us that behind every statistic is not just a life but many lives, the brothers and sisters, mothers, fathers, sons and daughters of those who have suffered from medical errors and their aftermath.

I have been studying medical errors and patient safety for more than ten years, and I still don't understand it.  None of us do.  We know a lot more than we did a decade or two ago.  We know that medical errors and harm are not rare, comprising, in fact, a leading cause of death in this country.  We know that most occur while patients are receiving care from very well trained, committed and diligent professionals, and often happen in the nation's best respected Centers.   Meaning that everything we thought before - that such accidents are rare, and that they are generally traceable to "bad apple" doctors and nurses with deficient skills, an inclination to negligence, or both - that these assumptions were pretty much dead wrong.  

We also know that preventing healthcare-associated harm - from medication errors, missed diagnoses, delayed intervention, hospital infections, wrong site surgery and more - involves not one approach, but many.  Because the "war on harm," we now know, is a lot like the "war on cancer."  Just as "cancer" is many different conditions, so "errors" come in many forms, affecting patients in many ways.  And we are still learning about the causative factors, so that effective changes can be implemented, both locally and nationally.

Despite this complexity, however, we have learned to look at healthcare delivery in new ways that provide coherence to our War on Harm.  They involve how we design processes, the role of communication, organizational culture, the role of patient empowerment, and leadership.  More on this in future blogs.