The patient safety movement

Improving patient safety is a national movement. Most healthcare providers involved in this movement identify its origin with a meeting of 300 experts held in 1996 in the Annenberg Conference Center near Palm Springs, CA. This meeting was convened by professional organizations in response to several error-induced sentinel events in the mid-1990s that captured the attention of the public media. Among the convening organizations were the American Medical Association, the American Association for the Advancement of Science, the Veterans Administration, and the Joint Commission on Accreditation of Healthcare Organizations. The National Patient Safety Foundation grew out of this meeting, as did several other initiatives, including the Veterans Administration National Patient Safety Partnership and the National Academy of Medicine–Institute of Medicine’s (IOM) Committee on Quality of Health Care in America.

The IOM’s Committee on Quality of Health Care in America has published two reports. The first report, published in 1999, “To Err is Human: Building a Safer Health System,” stated that 44,000 to 98,000 people die annually from healthcare errors. That is, more deaths result from healthcare errors each year than occur from vehicular crashes. The second report, published in 2001, “Crossing the Quality Chasm: A New Health System for the 21st Century,” claimed that the gap between quality achievable and quality realized in healthcare is huge, as are the financial and human costs of this gap. To bridge the gap, a new “culture of excellence” must be created in healthcare that will demand much of quality processes, human factors, engineering, and leadership.

Leadership to drive improvements in patient safety comes from many sectors, including providers, payers, and patients. Patient advocacy organizations, such as the National Breast Cancer Coalition and the Genetic Alliance, are leading the consumer movement to improve the safety of healthcare procedures. The Leapfrog Group and the Midwest Business Group on Health are examples of payer coalitions that are demanding safer healthcare processes. Many provider organizations have developed major initiatives in patient safety, and others, such as the Institute for Healthcare Improvement and the American Medical Association, are supporting the initiatives of the National Patient Safety Foundation. All of these initiatives have one element in common: they recognize that healthcare errors are a challenge to the ethical foundation underlying the delivery of healthcare. This challenge must be addressed if lasting changes are to be implemented to improve the safety and quality of healthcare for patients.

Addressing the ethical challenge of healthcare errors demands effective leaders to champion the cause of patient safety in all settings where healthcare is administered, including hospitals, clinics, nursing homes, hospices, and the home. These leaders must work to eliminate the blame and punishment culture of healthcare, so that truth-telling can be encouraged and rewarded rather than suppressed out of fear of reprisal. Leaders can emerge from a variety of disciplines, including medicine, nursing, administration, risk management, quality, and technical support. The background of leaders is not so important; what is important is their commitment to safety, and their willingness to “walk the walk” as well as “talk the talk” of improving the safety and quality of healthcare.

Every healthcare specialty has its own safety issues. In radiology, safety means extracting sufficient information from a radiological procedure with the least patient exposure to radiation, and then interpreting this information correctly to detect the presence of an abnormality and arriving at a correct diagnosis. Missed abnormalities and incorrect diagnoses are healthcare errors just as grievous as medication errors and wrong-sided surgeries. The impact of radiology errors may be less obvious and not so immediate, but the consequences can be disastrous for the patient.

In radiological circles, there is some discussion of the IOM reports and the potential problems of healthcare errors. But there is not as much discussion as there should be. Radiology deals with the use of tools that have the potential to injure as well as help patients, and safety has always been a major concern in balancing risk and benefit in the deployment of these tools. This history equips radiological specialists with the skills needed to assume leadership roles in the movement to improve patient safety in all areas of healthcare. Now is an opportune time to exercise these skills and position radiology at the forefront of the safety movement in healthcare.