Don't Hurt Me, Don't Kill Me and Don't Make Me Suffer Needlessly

I have had a number of occasions to quote the gentleman who first wrote these words, but last week I finally met Roger Resar face to face.  Resar, a senior fellow at the Boston-based Institute for Healthcare Improvement and Assistant Professor of Medicine at Mayo, was addressing a room of healthcare leaders from North Shore LIJ Health System on the Global Trigger Tool, an innovative method for detecting, measuring and tracking adverse events, one that he helped develop.  Using it doesn't reduce harm, but it does make it detectable.  And this is a critical first step.

I had believed for a long time that the core issue in patient safety is identifying and preventing medical errors.  That view, I now think, is logical but wrong, or at least seriously incomplete, and this was Resar's message.  Patient safety is not principally about errors, he suggested, but about harm.   There are several reasons to defend this position. First, errors are generally hard to define and hard to detect. Additionally, studies confirm that most errors don't lead to harm.  It is simply not efficient to set our sites on the elimination of error from the hypercomplex environment of healthcare.  As a matter of fact, the pursuit of individual errors generally leads to interminable and vigorous debate about the relationship between the alleged error and the outcome.  Reputation and ego are often at stake.  Uncertainly prevails. This is a cul-de-sac and such discussions are mostly obstacles to progress.  Finally, when we focus on errors and away from harm, we tend to overlook many important opportunities to improve.  Today's "expectable" complication is an innovation away from the history books.

But wait, we say.  What about wrong-site surgery?  Or the calculation error leading to massive overdose and death in the ICU? Clearly these front page news events are as real as the connection between the fateful error and the tragic outcome.  We must pay attention.

Indeed we must.  However, these events are anomalous, describing a tiny fraction of all harm that occurs in hospitals today.  More than a decade after the Institute of Medicine opined that 100,000 patients a year die in hospitals due to "preventable adverse events"  we are hardly any closer to winning the war on harm.  The best studies suggest that three of every ten hospital admissions is still associated with an event that causes temporary harm, permanent injury or death.  It is time to change tactics.