No, it isn’t a secret that patients come to harm in hospitals. I find it a testament to human resiliency that the numbers aren’t even worse…
The Journal of Patient Safety report details the complexity of not only delivering safe care, but how hard it is to quantify errors (a good read -link appreciated). This, in particular, stood out as a way forward:
Needed changes involve not only doctors and hospitals but increased
participation by patients in their health-care decisions. Perhaps it is
time for a national patient bill of rights for hospitalized patients
that would empower them to be thoroughly integrated into their care so
that they can take the lead in reducing their risk of serious harm and
death.15
All evidence points to the need for much more patient involvement in
identifying harmful events and participating in rigorous follow-up
investigations to identify root causes
It is nothing less than a cultural revolution in healthcare that is needed. Much important progress has been made since “To Err is Human” came out. Clearly, much more needs to be done.
On a general note: Strong opinions and outrage are valid and important --these infections should not have happened --and those feelings should fuel a call to action. To which I offer this: As a veteran of Root Cause Analyses, I’ll attest to the fact that the obvious reason isn’t always the right (or only) factor impacting why things go sideways. Be wary of feel-good fixes that assuage guilt and assign blame. The end goal --to make change that keeps a bad outcome from happening again --is not well-served when the drivers are bias and emotion.
