Déjà vu All Over Again

I’ve been in the middle of the fight to improve the safety of medical patients (read: all of us) since the late 1980s, including the opportunity to be one of the founding board members of the National Patient Safety Foundation in 1997. By 1999, the medical profession began to acknowledge that there was a huge problem as extensive efforts were begun to change the way healthcare was delivered from a cottage industry mentality to a carefully choreographed human enterprise.

In 2013, the Journal of Patient Safety published a scholarly research piece by Dr. John James which presented carefully derived evidence that up to 440-thousand Americans were being killed every year by medical mistakes of all sorts. Worse, that horrifying figure of 440-thousand did not include those who were seriously injured by mistakes from wrong-site surgeries to fatal infections to wrong or missed diagnoses.

As that paper came out, proving the urgency, American healthcare was gearing up massive efforts to change their culture to embrace the same safety methods that had worked so well in reducing airline accidents almost to zero. Physicians and nurses were being taught to work in communicative and supportive teams, and checklists appeared in operating rooms and emergency departments to cancel anticipatable human errors. 

(In fact, these are the very same successful methods of teamwork, coordination, and pride that prove so successful when corporations treat their people more like a family than a collection of assets. The major business biography I’ve been working on which will release this Spring  – The Nine Lives of Cristal Global – will illustrate this in great detail). 

Overall, by roughly 2015, healthcare leaders were largely recognizing that any human system that expected 100% perfect performance from humans was doomed to failure from the start (we humans will always make errors). In response, across the spectrum of American healthcare, we were making great strides in showing dedicated physicians and nurses and techs (as well as hospital CEOs and boards) how to build internal systems that could anticipate, catch, and cancel medical mistakes before they could hurt or kill a patient. 

It is certainly true that these highly successful methods of safe operation in a human enterprise had been pioneered in aviation, nuclear power generation, and in the construction of large and complex buildings. It is also true that such methods were not originated in healthcare, and thus the “not invented here” attitude sparked a decade or so of pushback from those who also embraced the phrase “This is the way we’ve always done it” to justify not changing. But slowly, the medical profession – which has at its heart the intense desire to cure and make lives better – began to change course.  By 2018-2019 we didn’t have the overall death and injury statistics to prove that safety was improving, but most of us were convinced we were making good progress and saving lives in large numbers. And now we know it was working! We have new scholarly papers indicating that patient safety was being markedly improved between 2011 and 2020.

And then came Covid, and the ensuing three years of massive disruption in American healthcare.  Understandably, the first year was especially fraught with an “all hands on deck” mentality that precluded normal educational efforts. But after the third year of hospital leadership focusing almost exclusively on finances, it has become painfully obvious that we have lost our way. Too many hospital leaders are quietly urging us to use less incendiary terms than “patient safety”, and in essence are using Covid as an excuse to leave all the previous efforts behind. To make matters more acute, the insidious multi-decade campaign to drastically reduce the ability of truly injured patients to sue for redress has now become so effective that hospitals have a greatly reduced fear of malpractice litigation. That, in turn, lowers the urgency of medical leaders to dedicate their institutions to zero harm. 

While no one to my knowledge in healthcare has yet uttered these words, the callous rebuff of an airline leader back in the ’80s to a request for better safety training still rings in my memory: “Why do I need to spend money on safety?” an airline CEO I knew asked with a snort, “That’s why we buy insurance.”

How long before that attitude creeps into the heart of hospital leadership?

Here’s what you should know. Almost all substantive training and instilling true culture change for keeping patients safe remains suspended or cancelled. Hospital leaders in particular, who admittedly are fighting massive revenue losses, are assuming that the advances we made before 2020 in changing the culture of medical practice have become permanent, but that is almost universally false. In fact, in today’s environment in which there is a critical shortage of nurses and massive pay disparities, it takes extraordinary and courageous leadership to keep concentrating on (and paying for) the lessons of patient safety, let alone campaigning for zero preventable deaths.

And where there are too few of such courageous leaders, our lives are increasingly at risk.

This is a pure guess, but it is one derived from nearly 30 years of experience. If Dr. James was to re-do his study today, I would be astounded if the annual death toll didn’t show above 750-thousand.

Hospitals operate under a license to serve their respective communities, and charitable donations from their nearby citizens across the United States are a mainstay of hospital income. If a hospital administrator realizes his or her community is concerned about what is being done to keep patients safe, things will change. Your voice is vital in this fight.