Feature articles by James P. Bagian, MD, PE; and Steven C. Winokur, MD and Kay J. Beauregard, RN
Five years ago the first IOM report To Err Is Human hit the streets. Its documentation of the unimaginable and unnecessary numbers of injuries and deaths caused by preventable errors has raised national awareness, and every provider, accrediting agency, and insurance organization is anxious to turn this trend around. So, how far have we come since that first report? Where should we be? And what do we need to do to get there? Frontiers called upon recognized leaders in the field of patient safety for their views.
The first article, by James P. Bagian of the National Center for Patient Safety at the VA, presents an interesting and important case for distinguishing between preventing harm and reducing or eliminating errors. It is essential to eliminate errors, but reducing harm, which encompasses reporting and learning from close calls that never make it to the error stage, is more effective and certainly less costly to the patient. Bagian elaborates on the components of the VA’s patient safety program and provides some very impressive results.
The second feature article is written by Steven C. Winokur and Kay J. Beauregard, both at William Beaumont Hospital in Royal Oak, Michigan. For Winokur and Beauregard, the essence of patient safety is about dignity and respect. Patient safety cannot be separated from employee, visitor, and caregiver safety. “Safety is safety.” The authors describe the patient safety initiative at their hospital and suggest that participating in collaborative efforts and sharing best practices with other organizations are critical for both large and small hospitals.
The commentators were drawn from the world of practitioners as well as from academia. In the first commentary, John Ferguson and Robert Fakelmann of Hackensack University Medical Center are struck that we are still talking about creating cultures of safety rather than working on the next phase, which is creating a reliable healthcare delivery system. They describe some of the common features of such a system as well as the barriers to making it happen. Julie J. Mohr from the University of Chicago argues that although it seems that little has changed, in fact the small changes to date have been consequential changes. She cites three broad categories of progress. James B. Conway of Dana-Farber Cancer Institute, in the third and final commentary, suggests that modest increases are not enough and that fundamental change is necessary to get us where we want to be. He adds that patient- and family-centered care must be expanded and that patient safety needs to be placed on the daily agenda of the C suite in every organization.
These articles provide excellent insights into what can and must be done to accelerate progress toward providing safe and reliable care to patients in each and every healthcare organization. Toward that end, it is important to share stories and experiences and keep the conversation going. As Dr. Bagian says, “Safety is a never-ending marathon, not a sprint. The results are worth the effort—our patients deserve nothing less.”