By: Dr. Michael Ramsay, Chairman of the Board, Patient Safety Movement Foundation
Every clinician, nurse, clinical practitioner, and health care system wants the best outcomes for their patients. Lucian Leape was one of the first to discuss the topic of patient safety as a driver of positive health outcomes. His new book, Making Healthcare Safe, discusses the history of the patient safety movement.
This update on patient safety by one of the great pioneers in the field helps those involved that can make a difference. In the book, Dr. Leape sets out to tell readers about the basic concepts of error prevention. This includes not only clinicians, but all health care professionals, hospital administrators, policymakers, and patients. Reading the book, they can learn how to create a culture of safety in our health care systems.
Dr. Leape worked with the Institute of Medicine (IoM) – now the National Academy of Medicine – to publish a report called “To Err is Human” in 1999. The report stated that 44,000 to 98,000 people died each year due to medical error. This, we now know, severely underestimated the true number of cases, which is more likely 200,000 to 400,000 deaths in the USA, and many millions globally. When we add in patient harm resulting from error, this number rises astronomically.
From Dr. Leape’s contributions to the 1999 IoM report to his recent book, it is clear that patient safety has come a long way. Simulation, training, monitoring, research, and education has improved and so, too, has the standard of care. Lucian Leape recognizes the groundbreaking work of the Anesthesia Patient Safety Foundation that pioneered human factors principles, among other methods, to dramatically improve anesthesia care and safety.
We are making progress in patient safety. The Patient Safety Movement Foundation is making a difference; more hospitals are embracing a culture of safety, transparency, and a “just culture.” The Patient Safety Movement Foundation, in this time of moonshots, has launched its own ambitious moonshot of Zero Harm by 2030. We are working with and supporting multiple efforts from different entities globally to get there.
However, we still have a long way to go. Many of you may have seen the new television miniseries on Peacock, called Dr. Death, starring Joshua Jackson, Alec Baldwin and Chris Slater. Dr. Death is based on the true story of Dr. Christopher Duntsch, a neurosurgeon living in North Texas. In 2017, he was convicted and sentenced to life imprisonment for killing and maiming patients under his care. How could this happen? Why was he not stopped earlier? The system, as much as it must embrace system mistakes, and publicize and fix them, must also maintain accountability. If patients are harmed because proper and safe practices are not maintained, this must be addressed immediately.
Everyone must be empowered to speak up without the risk of retaliation when patient safety is the concern. Patient safety must be number one, and certainly above egos, financial interests, and concern about litigation. The CANDOR program has demonstrated that full immediate disclosure saves money and saves lives. Dr. Leape has been a strong advocate of transparency, aligned incentives and strong oversight. Let’s make this happen!
Dr. Death must be a wake-up call to everyone in the healthcare system, a reminder that we must all protect our patients from harm — and must intervene when we see substandard care harming patients.
Never let your guard down and SPEAK UP! During one talk I was giving on patient safety, a young nurse stood up and said “we must all become Patient Safety Soldiers and keep our patients and colleagues safe.” That was well said and very meaningful!
Mike Ramsay, M.D.
Chairman, Patient Safety Movement Foundation
Past President, Baylor Scott & White Research Institute, Dallas, TX
Chair Emeritus, Department of Anesthesiology, Baylor University Medical Center