The publication in 1999 of the Institute of Medicine report, To Err Is Human, informed the public that almost 100,000 patients a year die as a result of medical errors. Since that time, there has been lively debate and dialogue about the accuracy of that measure, but more importantly there has been concerted national attention to develop strategies that will mitigate the rate of medical errors.
The growth of Hospital Medicine has coincided with the increased focus on quality and patient safety in healthcare. This has resulted in a unique opportunity for hospitalists to be both leaders and participants in identifying the facilitators for and barriers to creating and sustaining a culture of safety. As Hospital Medicine grows in size, scope, and accountability, the role of hospitalists in improving care and safety must also continue to expand.
An organization that has a robust culture of safety encourages all of its members to view their role and work through a lens of personal accountability and systems improvement. The identification of patient care concerns is encouraged at all levels and in all dimensions of the organization, and is reviewed with the goal of redesign to optimize safety. In a safe culture responsible actions are taken to improve care instead of inaction manifested by complaining and refusal to be part of solutions.
An organization committed to patient safety has leaders who are visibly dedicated to change and reporting. When organizational leaders do not openly value safety as the paramount goal, staff members are often unwilling to report adverse events and unsafe conditions because they fear a punitive response or believe reporting will not result in any review or change. As an organization moves to begin to promote a culture of safety, a key first step is to address the overt and subtle ways that reporting issues has had punitive consequences. For example, staff who report patient care concerns may not be included in committees or councils, or their opinions may be downplayed because the focus is on maintaining the status quo rather than actively identifying care concerns in an ongoing manner. However, the shift from a punitive approach to one that emphasizes safe system design must balance the role of the system with individual accountability to adhere to established standards and processes.
Marx has identified four behavioral concepts that are important to understanding the interrelationship between discipline and patient safety: human error, negligence, intentional rule violations, and reckless conduct. A systems approach to improving care primarily addresses the errors that occur as a result of human error without any intention to harm or disregard an established standard. As one reviews negligent actions, intentional rule violations, and reckless conduct, the review of the systems within which these events occur must be balanced with individual accountability and intention. Ultimately, an organization that has a robust culture of safety has processes to review and fix systems and to address individual accountability.