Physician-Patient Relationship

To protect patients from harm, skip shame and blame

Jennifer Lubell , Contributing News Writer

AMA News Wire

To protect patients from harm, skip shame and blame

Jun 13, 2024

A study published last year found that nearly 24% of inpatients experience an adverse event, despite nearly a quarter century of focus on improving patient safety since the landmark To Err is Human report published in 2000.

By contrast, more than 20 years ago, stakeholders in the airline industry came together and said: “We want to have a zero-harm, a zero-casualty policy,” said Marcus Schabacker, MD, PhD, CEO of the Emergency Care Research Institute (ECRI), a leading patient-safety organization. And since 2009, there have been no commercial airline casualties in the U.S. The health care industry needs to get to that same point, he said.

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“We are not doing enough, and we need to be doing more,” said Dr. Schabacker, who joined Stephen Parodi, MD, executive vice president of The Permanente Federation for a “Permanente Live Webinar to discuss solutions for improving patient safety.

Patient safety dictates whether people stay or leave health care as a career—it can be a source of inspiration or moral injury, said Dr. Parodi, who is also the associate executive director of The Permanente Medical Group and vice chair of the AMA Integrated Physician Practice Section Governing Council.

As an industry, health care has been “on a multidecade journey to raise awareness … to set and activate the principles of what would be expected for highly reliable organizations,” he added.

The Permanente Medical Group is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine. Also, The Permanente Medical Group received Gold-level designation from the AMA Joy in Medicine™ Health System Recognition Program.

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Institutions in this article have been honored by the Joy in Medicine™ Health System Recognition Program.

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A systems-based approach

Improving safety involves a systematic approach that combines leadership, culture and a safe workforce environment. It’s also about creating a clinical operating environment that calls things out when they’re not right.

Eliminating health care’s shame-and-blame culture is a good place to begin. Patient safety starts with building a culture in which people—physicians, other health professionals, staff and patients—feel respected, said Dr. Schabacker.

The tendency now is to individualize mistakes rather than looking at what went wrong from a systems perspective.

“We don't provide the necessary training, the simulation, the learning system that helps us to stay agile and react to things near-term in real time,” Dr. Schabacker said. “We really need to change our approach holistically.”

Building a safe environment involves both patient and caregiver, he added. It calls for an agile learning system where positive behaviors and learnings are reinforced and where near misses or misses are identified and then amplified. 

The entire workforce—physicians, nurses, technicians, administrators, janitors and more—are all part of this team base where everyone has a voice and a role in promoting safety for the patient.

“That's what it's going to take. This total system approach has been proven to be very successful. We just need to apply it. We don't need to reinvent the wheel,” Dr. Schabacker said.

Simulation is used by other high-risk industries such as aviation or the military to improve safety for employees, he added. Sometimes, when appropriate, it’s used in connection with virtual reality. Bottom line: simulation and repetitive training, coupled with team-based approaches, checklists and other cognitive material, help staff deal with out of the ordinary situations.

If an anesthesia unit doesn’t, for example, train for malignant hypothermia—a rare, but catastrophic event—the patient could die if there isn’t a checklist of what to do or where to get medications ready at the bedside, Dr. Schabacker said.

Learn more about how the AMA is leading physicians’ efforts to measurably improve patient safety and quality of care.

Drs. Schabacker and Parodi also addressed the need to ensure that health equity is addressed as part of efforts to improve patient safety.

The Advancing Equity Through Quality and Safety Peer Network Series is a set of free, online CME activities on the AMA Ed Hub™ that help learners integrate equity into their quality and safety infrastructures.

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