I participated in the Institute of Medicine webcast on Dec. 9 and here are some comments: To start with, both talks emphasized that the report has led to much positive awareness and advocacy of the patient-safety problem. In conclusion, both talks admitted the immense complexity of the problem and the many challenges ahead. My understanding with regard to the challenges was that more than being organizational or economic, the real challenge appears to lie at a conceptual level. Over the decade, hospitals have turned to defining the problem systemically and to reduce errors, thus moving away from the traditional method of reviewing the problem in terms of “individual” errors. The systems' approach, as I understand it, involves building a model of patient safety in terms of a process that includes all the individual persons and activities that play a role in the patient-safety outcome. The model allows the monitoring of each activity and person in the system and the possibility to review outcomes. However, there are shortcomings to this approach as noted by the speakers because of the lack of required scientific research and the complexity of hospital environments. It is thus interesting to review these shortcomings in light of the IOM report, as it first contrasted the positive safety numbers in aircraft travel with the negative safety numbers during a hospital stay. The reason for better safety records in aircrafts is because of the lack of a similar complexity as well as the availability of required scientific research. Ensuring aircraft safety involves a mechanical process, as does the mechanical process of building a car. The problems of hospital safety involve myriad human actions and interactions that cannot be defined as precisely as a mechanical system. This is why it is easier to fix problems of aircraft failure, as noted by one of the speakers. Looking to the future then, an analogy with biological or linguistic models based on human beings as central agents, might yield closer desired outcomes. This approach might also imply a gentle shift to reintroduce the “individual” as central in a process for healthcare improvement. Systems can only improve through modeling human actions. And they can only improve if each “individual” is back in charge of their actions. The coming decade of the patient-safety movement might benefit from a new report like To Err is Human—To Improve Divine.
Avani ParikhAvani Parikh ArchitectureNew York