A 2003 conversation with Lucian L. Leape, MD, Patient Safety Expert
Q: Right now, there is a lot of will to improve patient safety and plenty of literature to go with it. What makes change so difficult?
A: Well, we’re talking about behavior change and change in routines and practices; change of any kind like that is always difficult. What makes it even more difficult at the present time is that all of the parties are under fairly high levels of stress and overwork. The continuing ratcheting down of reimbursement and ratcheting up of belt-tightening in hospitals has created an environment that puts people in a defensive mode and makes it harder for them to take on additional responsibilities or do something different. The nursing shortage is real — a crisis that is already here — and it is sometimes difficult to talk about quality of care or safety when you’re concerned with survival.
In addition, part of what we’re doing is to change the way people think about their work and to move the emphasis away from being solely on individual performance and onto systems. That new way of thinking about things is foreign to most people in health care, and so they have to not only get over the hurdle of making change but also learn new ways of doing things.
Q: What are some specific examples of really promising work in the area of patient safety?
A: People are talking more and more about teamwork — helping doctors, nurses, pharmacists, and other health professionals work together better as teams — and about full disclosure of mistakes to patients. And I think that the now very widespread and continuing implementation of safe medication practices has been very impressive. Many, many hospitals all over the country have taken to heart the recommendations from the American Hospital Association, the Institute for Safe Medication Practice, and other groups.
Implementation of computerized prescribing is progressing faster than some expected, although not as fast as many had hoped. Despite a great deal of resistance because of the associated expense, it looks as if a large number of hospitals are making plans to implement it over the next year or so. That is a very important development because it is a high-leverage change. More computerizing and automation of the whole medication system will do a great deal to reduce medication errors, which are about one-fifth of all of the mistakes that we know of. That’s a major, major improvement.
There has been a lot of progress in hospitals reducing their punitive approach to mistakes and creating a non-punitive environment. The Institute for Healthcare Improvement (IHI) has been instrumental in fostering both types of change with its Breakthrough Series Collaboratives on medication safety. And so I think these are very impressive signs. Now we’re moving on to other areas — wrong-side surgery, restraint issues, various other safety concerns, teamwork, as well as training in the emergency room and now in other parts of the hospital.
Q: What progress have you seen on the non-punitive approach to error reporting?
A: The concept is that people make errors all the time — not because they’re incompetent or uncaring or careless, but rather because of the complicated systems they work in, which really make it difficult not to make mistakes. Because there are so many ways to go astray, it is not appropriate for people to be punished when they make mistakes, and yet that’s exactly what we’ve always done in the past. When people, particularly nurses, make a medication error they are disciplined, but what we’re saying now is that’s not appropriate. Nor is it effective in terms of reducing the odds of a next mistake. We shouldn’t punish people who report mistakes, but rather we should look upon mistakes as evidence, clues if you will, of a faulty system, and create an environment where people feel comfortable about reporting and discussing them. That kind of a non-punitive environment is essential if we want to get people to do something about preventing mistakes.
What we’re finding is that more and more hospitals are having success at doing this: Luther Midelfort — Mayo Health System in Eau Claire, Wisconsin, USA, is a very good example. The reporting of events goes up by orders of magnitude of 10, 20, 30, or 40 once people know that it’s safe to report and that there is some interest in it. So creating an atmosphere where people on the front lines trust that management is indeed really interested in understanding errors rather than in just punishing people makes a tremendous difference in how people feel about their work. It’s really the first step in creating a culture of safety where everybody takes responsibility.
Q: In places like Luther Midelfort, if reporting of errors goes up, can’t people say, "You’re making more mistakes"?
A: One of the things they did at Luther Midelfort, and that is necessary to do at any hospital when it makes this kind of change, is to make sure everybody understands that more reports doesn’t mean more errors. It’s important for the front office and the board of trustees to understand that in punitive environments most errors are not being reported. Once we foster less punitive environments and better reporting, we can look to define improvement, not in terms of reports, but in terms of specific types of events.
What health care organizations that are making progress, like Luther Midelfort, do is focus on a specific issue, for example complications of anticoagulation therapy. They can measure that; they can measure the number of patients who are on Coumadin, for example, whose blood anticoagulation level is out of the therapeutic range. And then they can put in a program to improve that pattern and show that the number of people out of range has been remarkably diminished. And that’s exactly what Luther Midelfort has done. Fairview Southdale Hospital in Edina, Minnesota, USA, has done the same sort of thing, and there are a number of other hospitals in the IHI Collaboratives that have demonstrated this type of improvement. Reporting of errors will go up when you make it safe to report errors. In terms of showing that there is improvement, you look at specific types of errors and you measure them very closely and use that as your indicator of improvement.
Q: It sounds like this is where leadership becomes really important.
A: Absolutely. People on the front lines have to trust their supervisors, and the supervisors have to know that the leaders will back them up. The hospitals that have succeeded in doing this have succeeded because the CEO understood and supported this principle and made it part of the mission of the hospital.
Q: When I hear people talk about things like establishing a culture of safety, teams, full disclosure, patient empowerment, etc., they all sound like such obviously good ideas. Why are they are so difficult bring about?
A: The fact that we’re talking about things that sound so obvious is a measure of the dysfunctionality of the modern health care system. This is of course what Don Berwick [former President and CEO, Institute for Healthcare Improvement] has been saying in another way for ten years: Health care has a number of features about it that are really unhealthy. For example, there’s been a lot of study of institutional behavior, and institutions can be characterized as learning organizations or progressive organizations — and by other buzzwords — but hospitals tend to be on the dysfunctional side. When something goes wrong, the interest is not in finding out what happened so it won’t happen again, but rather in trying to keep the information from getting out because it will make us look bad. So there’s much more interest in cover-up than in understanding. And physicians have long been told by the lawyers on the hospital staff that they should never admit to the patient they’ve made a mistake, because that information can be used against them in court. Well, that makes it pretty hard for them to admit to a patient that they’ve made a mistake. Those are all symptoms of a dysfunctional culture, and that’s why some of these things that seem so obvious and simple turn out to be very major. So what we’re talking about is a fairly profound revolution in the way people think about themselves and their work.