A blueprint on patient safety

By Lucian L. Leape

Seventeen years ago, Boston Globe health columnist Betsy Lehman died shockingly of a medication error at Dana-Farber Cancer Institute. That such an event could happen in one of the finest institutions of its kind in the world shook the public and the medical community. The reverberations from her death are still being felt, and they are continuing to lead to the improvement of health care around the world.

The latest example is the publication earlier this month of the second version of a report that has already had a remarkable impact on how hospital administrators approach the management of adverse events. The report’s four co-authors include James Conway, the person who was hired by Dana-Farber in 1995 to be its chief operating officer in the wake of Betsy Lehman’s death.

Under Conway’s leadership, Dana-Farber transformed itself. A key element in that transformation was transparency; being open and honest to the public, to the patient, to staff, and, for Dana-Farber’s leaders, to themselves. In 2004, with Conway still on the job, the Boston Globe reported that "Dana-Farber has emerged as one of the most safety-conscious hospitals in America.''

The new report – titled "Respectful Management of Serious Clinical Adverse Events'' (and available at www.ihi.org) – is published by the Cambridge-based Institute for Healthcare Improvement, where Conway is now a senior fellow. The report underscores the crucial role that transparency plays in improving safety. It provides a blueprint for hospitals to respond to adverse events in ways that are respectful to and supportive of those who have been harmed, and their families, while also improving care. It encourages hospitals to publicly admit their errors, be honest with those affected (including the staff involved), and learn from mistakes, so that they are not repeated.

What’s most remarkable about the report is the response that it has received since its first edition was published a year ago. It has been viewed online more than 33,000 times and downloaded more than 10,000 times; its content has been used in presentations at the Harvard School of Public Health and at health care-related institutions across the United States and in Australia, Ireland, Israel, Scotland, and Singapore, among other places. Health care organizations around the world are using it to help guide the management of serious adverse events.

That’s an extraordinary response from a health care industry that has historically responded to medical errors, especially those in which a patient unexpectedly dies, with a terse "no comment'' publicly and too little self-examination privately. Instead of a focus on containing reputational, legal, and financial damage, the report calls for a focus on healing of the emotional wounds of both the patient and the caregivers, sometimes called "second victims.'' It calls for taking responsibility and for communicating openly. The fact that it is being widely read is an encouraging sign that hospitals are now beginning to embrace this concept.

Transparency is one of the reasons that commercial aviation in America has such an impressive safety record. When an airplane crashes, the National Transportation Safety Board swoops in and launches a full investigation: entire planes are re-assembled; press conferences are held to update the public; a report is issued on the investigation’s findings; the entire industry is informed, and corrective measures are required of all similar aircraft.

Health care innovators, like the Institute for Healthcare Improvement, have been working to transfer those lessons and practices from aviation – and other fields with impressive safety records – to health care. The response to this report demonstrates that a change in attitude is starting to take hold.

It’s about time. It was 12 years ago that the Institute of Medicine published its landmark report, "To Err Is Human," that revealed that "as many as 98,000 people die in hospitals each year as a result of medical errors.'' Its major conclusion was that "the majority of medical errors do not result from individual recklessness or the actions of a particular group – this is not a 'bad apple' problem. More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them.''

That’s precisely why transparency in responding to adverse events is so important. In order to improve the faulty systems, we have to understand them: what went wrong and why. Only by acknowledging errors and investigating them can we avoid them in the future.

That’s what makes this new report so important. It may only be read by healthcare providers, but if it changes how hospitals deal with their patients and the broader public when mistakes are made, it will lead to safer health care for all of us.

It took the death of a Boston Globe health columnist to change the culture at one of America’s greatest cancer institutions. It’s time to change the culture across the entire health care industry.

Dr. Lucian Leape is adjunct professor of health policy at the Harvard School of Public Health and chairman of the Lucian Leape Institute of the Boston-based National Patient Safety Foundation.