Two icons of patient safety, Peter Pronovost (Time magazine’s Top 100, 2008) and Ara Darzi (British House of Lords) have recently penned a manifesto. It calls for a systems approach to safety assurance and less reliance on heroism to make up for weak systems. The document is well written, persuasive and wrong. Well, not wrong, just not right!
Let’s start with the systems point. The argument put forward by Pronovost and Darzi echoes a constant refrain from safety pundits that goes something like this:
However, it would seem more reasonable to conclude that health care is not like other industries – as argued in a previous post, only about one quarter of AEs arise from archetypal system problems in the sense that their root cause lies in the host organisation. The remainder follow diagnostic errors (broadly defined) and procedure-related errors. These both lie in the province of front-line doctors failing to exhibit sufficient skill. Of course manifest skill can be influenced by local conditions, for instance if the doctor has to care for more patients than she can cope with. And they emanate from a broader system concerned with selection, training and so on (see ‘Bring Back the Ward Round’ below). But it is hard for a hospital to indemnify itself against a surge in demand, and recruiting and training doctors plays out over decades.
Things that can be systemised are being addressed to good effect. Hospital-acquired infections are massively down; severe pressure ulcers down; medication error heading south; and wrong site surgery is right down.
The patient safety ‘industry’ needs to move on from its preoccupation with infection, falls, medication errors, pressure ulcers, and rare egregious errors. And to be fair, Pronovost has campaigned elsewhere for more emphasis on diagnosis, while Darzi is a world leader in surgical training.
And that is where we need to turn to this issue of heroism. Here the story goes something like this:
Now I am not arguing for the return of Sir Lancelot Spratt and fully understand that it is patients, not doctors, who put their lives on the line. But treating health care workers like office clerks is wrong – again and again clinicians have to go above and beyond, doing hard cognitive, physical and emotional work – a good doctor, has to ‘give of herself’.
A good doctor who has done a hard night in A&E has not just spent the evening following guidelines; she has made sound judgements under uncertainty, maintained her composure under abuse, coped with a stream of patients arriving faster than they can be seen, and she has kept a cheerful demeanour throughout. She may have helped hit the government’s four hour target. Doctors in many parts of the world feel demoralised, but medicine cannot go back to the hands-off approach of yesteryear – scrutiny and regulations are here to stay for very good reason. But don’t let the pendulum swing too far – recognise that the work is hard, that it cannot be completely codified, and that it is deeply personal, and leave space for just a little heroism.
— Richard Lilford, CLAHRC WM Director
- Pronovost PJ, Ravitz AD, Stoll RA, Kennedy SB. Transforming Patient Safety: A Sector-wide Systems Approach. Doha, Qatar: World Innovation Summit for Health. 2015.
- Newman-Toker DE, & Pronovost PJ. Diagnostic Errors – The Next Frontier for Patient Safety. JAMA. 2009; 301(10): 1060-2.
- Singh P, & Darzi A. Surgical training. Br J Surg. 2013; 100: 307-9.