Patient Safety Commitment to zero patient harm and preventable death is the first step towards achieving it.
Millions of healthcare patients in the U.S. are harmed annually; and tragically, studies show that some even die from preventable adverse events. Healthcare-associated infections, harmful medication errors, wrong-site surgeries and surgical fires are just some of the ways patients are being harmed needlessly. This is not acceptable. We must strive to reduce the incidence of preventable patient harm until the number is zero.
“Adapting and applying the lessons offers the promise of enabling hospitals to reach levels of quality and safety that are comparable to those of the best high-reliability organizations.”
As an industry, healthcare has always pledged to do no harm, but the capability to eliminate preventable patient harm has been elusive. There are a multitude of current approaches to improving healthcare; and while some are making inroads, the pace of overall improvement is not satisfactory. In an article I co-authored with the late Jerod M. Loeb, Ph.D., we emphasized that it is essential to look to outside healthcare for solutions.
These solutions come from the study of organizations in industries, such as commercial aviation and nuclear power that operate under hazardous conditions while maintaining exemplary safety records that are far better than those of healthcare. Adapting and applying the lessons offers the promise of enabling hospitals to reach levels of quality and safety that are comparable to those of the best high-reliability organizations.
For example, according to 2012 data from the U.S. Department of Transportation, the U.S. airline industry was extraordinarily safe during the 1990s. From 1990 through 2001, U.S. commercial aviation averaged 129 deaths per year from accidents and logged an average of 9.3 million flights per year, translating into a death rate of 13.9 deaths per million flights. In the next decade — from 2002 to 2011 — that death rate plummeted by a remarkable 88 percent to 1.6 deaths per million flights. Even though the average annual number of flights increased to 10.4 million per year, the number of deaths dropped to an average of 16.6 per year.
The lesson for healthcare is not to be satisfied with modest improvements. Aiming for zero harm is the first step toward achieving it.
In order to get to zero, healthcare organizations must first commit to the process of becoming a “high reliability” institution. The Joint Commission has developed a framework for hospitals that integrates high-reliability science and our considerable experience working with the thousands of healthcare organizations that we accredit or certify.
Many healthcare leaders are reluctant to commit to the goal of high reliability because they regard it as unrealistic, unachievable or a distraction from their current serious fiscal and regulatory pressures. One of the important roles for policymakers and stakeholders is to encourage, persuade and demand that healthcare organizations embark on this journey. The Joint Commission also encourages and invites them to join us on the journey to high-reliability, because all patients deserve safe care.