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Whooo Says…

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Dear Whooo,

I am a hospital librarian, and have only been in this position for a short time. I’m trying to familiarize myself with healthcare and all of the multiple topics and challenges so that I can serve my constituency better. I keep hearing about patient safety in the hospital setting and am starting to understand how much effort is devoted to that issue. I also hear criticisms about safety rates in the hospital environment being so different from the aviation industry. Can you help me understand this?

Interested Wonderer

Dear Interested,

I’m so glad to hear from you. You have asked a question that is of great importance to me and probably one of the most significant in healthcare today. It is also a huge and complex question that would take volumes to answer so I will give you a few basic thoughts and some authors to look for in your readings on the subject.

To start, aviation safety in the United States encompasses the “theory, investigation, and categorization of flight failures, and the prevention of such failures through regulation, education, and training.”1 Safety has been a concern of the aviation industry since the 1920’s and the passage of the Air Commerce Act requiring licensure and examination for pilots and aircraft, the proper investigation of accidents, and the establishment of regulations and safety aids under the Aeronautics Branch of the US Department of Commerce. Since that time, additional concern has emerged and further regulation developed. Safety rates have increased due to improved aircraft design, engineering and maintenance, evolution of safety aids and safety protocols and procedures. Now air travel is reported to be the safest form of travel in terms of distance moved.

Hazards affecting the safety of air travel include such things as foreign debris, misleading and/or lack of information, lightning, ice and snow, engine failure, structural failure, fire, bird strike and human factors (pilot fatigue, pilot intoxication, controlled flight into terrain or electromagnetic interference – certain devices are known to interfere with aircraft operation). There is mandatory accident reporting and investigation carried out by the National Transportation Safety Board, and reports and accompanying information is filed with the Aviation Safety Reporting System.

The comparison to patient safety is really quite interesting. Though healers and medical personnel have been aware of and concerned with the potential for injuries caused by well-intentioned actions since the days of Hippocrates, patient safety is a relatively new discipline. It arose in the 1990’s after work in anesthetic accidents in the US, Britain and Australia raised the awareness of the number of patients who die or suffer brain damage from these accidents. By 1999, the Institute of Medicine had released the seminal report “To Err is Human: Building a Safer Health System.” This report called for establishment of a Center for Patient Safety, expanded reporting of adverse events, development of safety programs in health care organizations, and attention by regulators, health care purchasers, and professional societies. The majority of media attention, however, focused on the staggering statistics: from 44,000 to 98,000 preventable deaths annually due to medical error in hospitals, and 7,000 preventable deaths related to medication errors alone.2 Similar statistics were reported on other countries as well, and the World Health Organization has named patient safety an endemic concern, recognizing that healthcare errors impact 1 in every 10 patients around the world.

Major issues at the heart of patient safety are effective communication, teamwork, a culture of safety, and reporting of adverse events. Each of these issues is complex within itself, and the interaction between them plays out differently within units of the larger organization as well as in the organization as a whole. The goal of course is for these four factors to work effectively and form the basis of a well-functioning safety program.

On top of the four issues mentioned above, the major causes of healthcare error are:

  • Human Factors – includes variations in training and experience, fatigue, depression, burnout, diverse patients, time pressures, increased working hours of nurses, and a failure to acknowledge the prevalence and seriousness of medical errors
  • Medical complexity – includes complicated technologies, powerful drugs, intensive care, and prolonged hospital stays
  • System failures – includes poor communication and unclear lines of authority, patient to nurse staffing ratios (higher ratio increases problems), fragmented reporting systems affecting care coordination with patient handoffs, drug names that look or sound alike, reliance on automated systems to prevent errors, cost cutting measures by hospitals in response to reimbursement cutbacks, environment and design factors, infrastructure failures, etc.

In light of all this, it is important to remember that not all adverse events are caused by incompetence, error or high risk procedures. Errors occur at all levels of the health care environment, and many are caused by normal human slips, not poor judgment or recklessness. Also, just because there is an adverse event, the cause is not necessarily from error, but possibly from complications or side effects of the procedure or treatment.

Among the various efforts to minimize adverse events are the increasing use of technology (such as the electronic health record, computerized provider order entry – CPOE, standardized bar code systems for dispensing medications, etc.), evidence based medicine, quality and safety initiatives, health literacy programs, and pay for performance. Currently, programs for reporting adverse events are not mandatory in the US, though a federal reporting database was established in 2005 with the Patient Safety and Quality Improvement Act. Hospital reports of serious patient harm are still voluntary, confidential, and cannot be used in liability cases.

This is a very brief description of both aviation safety and patient safety, Interested. I encourage you to follow these issues carefully and find ways you can contribute to the patient safety effort. It is an effort that must not exist in the silos of individual departments but should include everyone involved in healthcare. We all have a role to play and the responsibility to perform our functions to the best of our abilities, looking for the lapses/incongruities in the system and the potential for error within our individual spheres such as the library. In healthcare, we all exist to take care of the patient in the bed.




1 Aviation Safety. Wikipedia. https://en.wikipedia.org/wiki/Aviation_safety Accessed December 23, 2016.

2 Patient Safety. Wikipedia. https://en.wikipedia.org/wiki/Patient_safety Accessed January 3, 2017.

The following authors and journals are good places to start your reading on the topic of patient safety.

Don Berwick, MD
Sidney Dekker
Atul Gawande, MD
Mark Graber, MD
Lucian Leape, MD
Peter Pronovost,MD
Gordon Schiff, MD
Hardeep Singh, MD
Robert Wachter, MD
Albert Wu, MD

AHRQ PSNet – https://psnet.ahrq.gov
Journal of Patient Safety
Joint Commission Journal on Quality and Patient Safety

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