In recent years, there has been no greater frustration in American healthcare than our collective failure to improve patient safety. At least 2 contributing factors are well known:
A payment system that winks at unsafe care; and
A medical liability system that blocks patient safety learning opportunities.
But the worst problem has been the failure of our medical schools to educate their students in basic patient safety concepts. Most schools provide no instruction in systems thinking, and no applied experience in examining the patient care processes, which constitute everyday practice in the real world of healthcare. Thoughtless design of care processes can and does permit human error to reach, and kill, patients every day. One would expect that teaching the prevention of iatrogenic patient deaths would be a priority in our nation's medical schools, but it is not.
Further, medical schools direct little attention either to the concepts of human factors or to the fundamentals of effective communication. Human failings – whether reflected by behavioral aberrations or by error resulting from worker fatigue – contribute to patient deaths every day. So do failures in communication. Almost 80% of preventable patient deaths are caused in part by communications failures.
When patient care disasters occur, there are at least 2 victims – the patient and the practitioner involved in the occurrence. But we teach our physicians to be victims – to believe that they are the origins of all outcomes, good and bad. But it is not that way. We need physicians who understand systems concepts and their implications, and who know how to diagnose and fix weaknesses in care processes.
Today's medical schools are producing square pegs for our care system's round holes. This problem requires their immediate attention. And we need a strategy for re-training the “damaged goods” doctors that we have already received.
That's my opinion. I'm Dr. Dennis O'Leary, President of the Joint Commission on Accreditation of Healthcare Organizations.
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