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Perhaps the single biggest blessing that any individual can thank his or her stars for is a sense of physiological and psychological well being that allows for the optimal utilization of one's lifetime. In the same vein, all humankind can perhaps also thank and bless the significant advances made by the medical sciences, which has resulted in the ability to cure many an illness and overall increase the average life span of humanity. Indeed, modern day humanity has only to look at its own history to truly understand the import of medical knowledge and aid. And it is precisely for this reason that it becomes hard to comprehend the fact that there still exists many lacunae in health care that is tantamount to the worst kind of social injustice. Take for instance, the shocking statistic that more deaths can be attributed to medical errors than car accidents or victims of AIDS. Not surprising, then, that there has been a great deal of attention in the recent past to the repercussions caused by preventable errors in the health care system. As a result of such attention, there is wide agreement that there is an urgent need to come up with effective solutions that will achieve a zero level tolerance. One such solution that has been suggested by many scholars and health care practitioners is the setting up of a safety culture akin to that of other high-risk industries such as aviation and nuclear enterprises. The proponents of a safety culture solution for the health care industry believe that the successful implementation of systems designed to ensure patient safety would result in eradicating premature death and needless injury and thereby assure the general populace of quality health care that will allow them to lead a full and rewarding life.
But first, to understand the imperative for instituting a safety culture, it is important to place in context the magnitude of the problem caused by medical errors. Though numbers are important in establishing the severity of the problem, highlighting the suffering caused by the injustice of a single premature death perhaps better drives the import and magnitude home. Take, for instance, the case of Betsy Lehman, a science writer for a leading newspaper who died on account of a massive overdose of chemotherapy, leaving behind her three and six-year-old daughters and a heart broken husband. Investigation into her death revealed not one, but more than half a dozen people at the Dana Farber Cancer Research Institute, who could have detected the dosage error over a period of two days but failed to do so: "the resident who wrote the amount in the chart, the pharmacists who released the dosage, the nurses who checked the chart and monitored the patient. Investigations exposed the lack of internal controls...monitor the quality of patient care...." Betsy Lehman's premature death was all the more tragic given the fact that the treatment had actually cleared her of the cancer and that her husband was a research scientist who actually worked at another part of the same institute. Betsy may be one single case, but even that is enough to make any patient wonder if they are submitting themselves to more than just the known and unavoidable risks of cancer treatment. With each such case, health care institutes betray the trust of those putting their lives on the line to assist themselves as well as lend future patients hope for a full recovery (Minnow, 60). The imperative for the health care system to institute a safety culture lies, therefore, in the fact that the system must do everything possible to retain the trust and confidence of the public in the quality assurance afforded by health care organizations and practitioners.
The injustice of just one anecdotal incident is shocking enough but the extent of the malaise is established by the statistics published in the Institute of Medicine (IOM) report that establishes the fact that the health care system is not as safe as it should be: "A substantial body of evidence points to medical errors as a leading cause of death and injury...at least 44,000 and perhaps as many as 98,000 Americans die in hospitals each year as a result of medical errors...exceeds the deaths attributable to motor vehicle accidents (43,458), breast cancer (42,297) or Aids (16,516)." (Kohn et. al, p. 26) The statistics then reveal the injustice done to Betsy Lehman multiplied manifold. And this in an era where biomedical science is purportedly on the verge of breakthrough cures for hitherto incurable diseases such as multiple sclerosis, cancer and Parkinson's disease.
Admittedly there is a dichotomy in that a field as advanced as medicine has yet to institute the practice of a safety culture. And, to that extent, perhaps it becomes important to analyze the root causes underlying the occurrence of medical errors or the absence of a safety culture. While there are many aspects such as organizational culture, external pressures such as insurance costs and fear of litigation and defects in design of equipment and staff procedures in diagnosis, treatment and dispensation of care that need to be addressed in delivering patient safety, it does appear that the big culprit is the fact that to date, few demands have been made on the health care industry. This is largely due to the fact that the public has a very limited understanding of both medicine as well as health care safety issues. The former is on account of medicine being such a highly specialized field but the latter is more because health care safety accidents or errors take place as isolated, often unreported, cases as against an aviation or nuclear plant incident which involves and affects large numbers of the population (Kohn et.al, p. 43).
Leading from the above, an obvious first step in instituting a culture of safety in the health care industry is to bring about sufficient external pressure that make errors costly to health care organizations and providers so they are compelled to take action to improve patient safety. Such external factors include availability of knowledge and tools to improve patient safety, strong and visible professional leadership, legislative and regulatory initiatives, and actions of purchasers and consumers to demand safety improvements. To provide and facilitate the institution and operation of the aforesaid factors, the IOM committee has recommended the setting up of a 'Center for Patient Safety' within the Agency for Healthcare Research and Quality (AHRQ) as it felt that the latter was best equipped to help the Center achieve its set objectives as it was already involved with a broad range of quality-of-care issues (Kohn et.al, p. 6, 77). Parallels can be drawn from other industries where initiatives taken by the external environment succeeded in bringing about desired results such as improved worker safety in the workplace or safer air and rail travel. Take, for instance, the role played by the FAA in aviation or OSHA in ensuring worker safety. Both agencies play a vital role in compiling, researching, analyzing and disseminating data that impacts safety besides conducting frequent inspections and taking regulatory action where and when called for (Kohn et.al, p. 73-75).
A key aspect of even external pressures to bring about safety succeeding is the importance of guaranteeing protection from legal action. One large reason for medical errors going unreported and the tendency to attribute blame on individuals is the fear created by the existing system of litigation: "...the medical liability system and our litigious society should be recognized as potential barriers to systematic efforts to uncover and learn from mistakes that are made." (Huston, p. 299) A good step in this direction is The Patient Safety and Quality Improvement Act that was introduced in the Senate in June 2002, which protects medical information voluntarily submitted to new private organizations from being subpoenaed or used in legal discovery. The mandatory reporting system instituted by some 20 states (Huston, p. 299) will also be beneficial in analyzing causes of medical errors and designing solutions to prevent recurrence.
While external pressures can be very effective in bringing about the necessary pressure on health care organizations and providers to focus on patient safety as an issue, it is critical that a simultaneous realization is brought about that patient safety involves changing of organizational cultures in order that both patients and staff are made aware of the enormous importance of the issue and that it is a focal point in delivering quality care. But more important, only a change in organizational culture that lays a primary emphasis on patient safety will result in several key actions: employing appropriate hiring and job assignment policies that ensure that errors do not arise due to fatigue or over-stress; design of work situations such as tasks, equipment and environment that avoid error likely situations such as deficient procedures, poor communication between workers, inadequately trained workers, conflicting worker interests, and poorly labeled or designed equipment; implementation of human factors engineering and ergonomics in order that jobs, machines, operations and work environment…[continue]
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