Berwick on safety

I have known Don Berwick for over 20 years. He is bright and charismatic. His deep seated interest in improving quality of care combined with a captivating ability to communicate has made him a major leader in health care policy. He has an op-ed in today’s Washington Post – Invisible Injuries

The Institute of Medicine, our nation’s most respected adviser on medical science, says that at least 100 patients will die in hospitals in the United States today because of injuries from their care, not from their diseases.

How many will die tomorrow?

Tom Nolan, one of the leading quality-improvement scholars of our time, identifies three essential preconditions for improvement of anything: will, ideas and execution. When it comes to reducing medical errors, America’s will and ideas are increasing steadily now, following the Institute of Medicine’s lead.

And yet, so far I see no evidence that health care in the United States is becoming safer. The ingredient we seem to be missing most is the third one on Nolan’s list: execution. Who will change the care? And when? At least four major roadblocks appear to lie between will and ideas, on the one hand, and execution, on the other.

Whoa!! Slow down Don. This op-ed starts with an assumption – that the IOM has correctly estimated the number of deaths caused by errors. Almost all experts who have reviewed this report argue that the number is markedly too high. The number is important, as it informs public perception of hospital care. It obviously informs Don Berwick’s perception.

Rather than fanning the flames, I would prefer a careful analysis of what errors happen most commonly, and how do we avoid them. This seemingly simple goal actually has such complexity that we will probably continue arguing about errors rather than preventing errors.

As a physician who spends almost half the year as a ward attending in a VA hospital, I see errors every day. We see errors of omission and errors of commision. The laboratory makes errors; the nursing staff makes errors; the pharmacy makes errors; we physicians make errors. Unlike many hospitals, we can tell when we make errors more easily because we do have an outstanding computerized medical record.

Over the past few weeks we have seen laboratory tests not collected, or collected and not performed. We have seen radiologic reports not filed for weeks at a time. We see medications not given, or not delivered. We are generally understaffed for the actuity of our patients.

At the risk of being chauvinistic, we need clinical physician leadership here. We are the coordinators of care. We must make the diagnoses and develop the management plans. However, we have little ability to insure that the other services (pharmacy, nursing, radiology, laboratory, dietary) have sufficient staff and sufficient accountability.

I would agree with Don Berwick that we must reorganize medical care. Clinicians should once again have an influence on who hospitals run. Administrators have (in my opinion) too much concern for the bottom line, and not enough for quality of care. Until they who run hospitals have care as a true priority we will see errors.

All that being said, few errors are major. I do not believe the IOM numbers. I do believe that we should strive to improve care. Physicians must lead the way. If they would only let us. (Damn that sounds whiny – I better think through this better, we should not let the current systems keep us from succeding). Berwick does hit the nail on the head:

Third, improving safety costs money in the short term — money for technical changes, such as new equipment, computerization and the redesigning of jobs, and money for cultural improvements, such as new training and support for better teamwork among doctors and nurses. Today’s stressed hospital executives often feel that they cannot afford to make these investments. A distant hope for long-term returns or vague calculations about how much patient injuries are costing today don’t often seem to carry the day in hospitals and clinics facing large and immediate financial losses.