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10 Years On: Lucian Leape Grades Patient Safety Movement


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10 Years On: Lucian Leape Grades Patient Safety Movement

By Tom A. Augello, CRICO

Related to: Ambulatory, Emergency Medicine, Primary Care, Nursing, Obstetrics, Other Specialties, Surgery

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Guest Commentators

Lucian Leape, MD; Harvard School of Public Health; Boston, MA


In December of 1999, the Institute of Medicine shook the medical world with a report, called “To Err is Human.” It is often seen as the birth of the patient safety movement in America. The IOM report’s claim that medical errors cause up to 100-thousand deaths was a point of alarm and controversy. The figure comes directly from research conducted by Harvard School of Public Health Adjunct Professor and retired pediatric surgeon Lucian Leape. Dr. Leape is widely considered a pioneer—if not the father—of patient safety. In 2007, the National Patient Safety Foundation announced the formation of the Lucian Leape Institute as a think tank and advocate for safe patient care.

Resource Managing Editor Tom Augello recently sat down with Dr. Leape to reflect on the impact of the patient safety movement 10 years after the IOM report….its successes…and its disappointments. In the first of a series of excerpts, Lucian Leape shares his observations from a national vantage point, about a movement that continues to dominate his professional energies.

Q: Dr. Leape, thank you for joining us.

A:My pleasure.

Q: It is now 10 years past the IOM report, which in many ways was based on the research that you did here at the School of Public Health. The basic question 10 years in is are we any safer?

A: And the answer is yes. Not as much as we’d like, but clearly more than we were… I think there is no question we’re safer. The Institute for Health Care Improvements 100,000 Lives campaign of several years ago showed a dramatic improvement, over 120,000 lives that they estimate were saved by implementing just six practices. As a matter of fact, very few of the hospitals that implemented all six; they had implemented varying numbers of them, but that was a big impact and all those gains have continued. We certainly have had some dramatic examples where there have been major improvements in safety. The most important of these is the experience in Michigan with Peter Pronovost’s work on reducing central line infections and then later associated pneumonias.

Q: Along those lines as you look at this sort of new era of openness or quasi-openness about error, when you think of the theory that you can’t really solve a problem until you acknowledge it and you sort of look at it and pay attention to the problem, do we have a good handle on the distinction between system flaws and individual mistakes that are negligence? Are we getting a better assessment of what the problem is and how to fix these?

A: Well, I think we in the patient safety community have a good handle on that, and that is the people who are responsible for patient safety in hospitals and around the country, I don’t think they have any problem with this at all. However, the public is certainly far behind on their understanding and even more worrisome, the legal system… I think what’s happened though that’s much more positive is the emergence of the concept of a just culture.

When we first began talking about patient safety, our emphasis was on getting people to quit punishing individuals when they made a mistake, and we said you should create a nonpunitive culture for error. People translated that into a no-blame culture which sort of was, in effect, ‘it’s okay to make mistakes and we won’t punish you,’ and they mixed it up with the problems related to taking responsibility and following safe practices. We have never said it’s okay to do what you want, it’s always a systems problem. What we’ve said is that errors are systems problems, but they are very different from misconduct. What’s the difference? Well, I think that deliberately refusing to wash your hands before you see a patient when that’s the safe practice and that’s the policy, I consider that misconduct. There should be consequences for that. On the other hand, forgetting to wash your hands when you walk in to see a patient is an error. So you don’t punish for forgetting, but you certainly don’t accept and tolerate deliberate infractions, deliberate refusal to follow safe practices. You can’t achieve safety if you tolerate that kind of conduct. So a just culture doesn’t punish for mistakes, but it doesn’t tolerate unsafe practice.

Q: Now when you look at the last 10 years, what’s been your greatest disappointment?.

A: It has been really disappointing to those of us involved in this movement that the chief executive officers and the medical leaders of hospitals haven’t owned this problem, haven’t said this is something we gotta do something about. We have made a lot of progress in terms of moving beyond the denial. When we first started, people said we don’t believe that. We don’t believe the numbers. You don’t hear that anymore. I haven’t heard anybody question the numbers for five years. Everybody knows we’ve got a problem. We also have moved on to the position that it’s our problem, that is hospitals now almost all have patient safety officers and patient safety programs. But we haven’t taken the next step, which has been to say and we’re going to do this all out full stop. Simple case in point, the National Quality Forum has carried on an extensive and outstanding process of identifying, validating and recommending safe practices. And they have now certified through an elaborate process which involves all the stakeholders 34 safe practices that they say every hospital should implement. Not a single hospital in America to my knowledge has a plan, a strategic plan, for implementing all 34. Most hospitals are implementing some. Some hospitals have implemented five or six of them. Very few hospitals have implemented even a majority of them. Why not? If these are things that we know will really make a difference in safety, shouldn’t it be the first responsibility? First do no harm. Shouldn’t it be their first responsibility of hospitals to implement all these practices?

Q:There was a recent study and survey of hospital board members about their sense of their responsibility for patient safety, and it showed that less than half saw that as a top priority for them, but they did see it as a measuring of the CEO performance but not necessarily a key board duty or a board role in patient safety. Do you see that this has to go up to that high level? .

A: I think the boards are where much of the medical establishment was 10 years ago. That is, they have just now been aware of the fact that it is their responsibility, and the message is coming through loud and clear. I mean, there is no question from a legal standpoint the boards are responsible for safety, and the hospital associations have suddenly wakened up to the fact that they better get moving on this, and so there is a very major program to raise awareness and ability, and I think we will see a big change on that.

Q: So where’s the disconnect? You’re saying we are not doing all we should be doing, that there are dozens of measures in the National Quality Forum that no hospitals following. So if the boards are aware of their role there in setting a strategy and the priorities, where’s it breaking down?

A: Well, first of it, this is an extremely complex problem. I mean, health care is the most complex industry ever invented by man… We’re really saying that we have to move away from the model we’ve used for 100 years, which was individual practitioners doing their own thing in their own way and interacting with other individuals and if everyone is an expert, things will work out all right, and what we find is it doesn’t work all right and so this is a huge culture change and, of course, it’s gonna be difficult and go slow. My own belief is that the boards will not drive this anymore than boards usually drive what happens in most corporations or banks. It’s the leadership that does it. It’s the CEO’s, executive committee and the leadership, and in hospitals that includes the physicians and the department chairmen, and those are the people that have to make these changes because they’re the ones that have to interact with the people in the frontline whose behavior they’re expecting to change.

Q: Are we still killing 100,000 patients a year?

A: Oh, I doubt it, although maybe we are and it’s 100,000 instead of 200,000. That’s sort of a perverse way of answering your question. I always thought our estimate was an underestimate, so …my feeling is we’ve probably reduced it substantially, maybe by 20 or 30 percent, but it’s still a big problem.

Thank you. Dr. Lucian Leape, Adjunct Professor of Health Policy at the Harvard School of Public Health. For Resource, I’m Tom Augello.

January 1, 2010
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