Let's focus on safety systems improvement, not individual blame

LETTER FROM THE EXECUTIVE DIRECTOR

Barbara Fain Headshot final

Barbara Fain, J.D., M.P.P.

The prosecution of health care professionals for mistakes in patient care is exceedingly rare. The recent negligent homicide conviction of nurse RaDonda Vaught for a medication error at a Tennessee hospital has provoked considerable consternation from frontline clinicians to patient safety groups (including IHI/LLI and ECRI/ISMP) and underscores our need to reframe the dialogue in order to advance, not erode, safety.

Patient deaths caused by medical errors disrupt commonly held notions of safety. The public, media and even frontline health professionals tend to react by focusing on the role of individual clinicians and staff. Who made the mistake? Who should get fired or sued to weed out the “bad apples”? Rarely is the safety of the systems in which these individuals work questioned or the accountability of organizational leaders for safety culture and operations considered. How to support members of the health care workforce so that they can do their jobs safely is another topic missing from most discussions.

Research by FrameWorks Institute, in partnership with the Betsy Lehman Center, explains how people tap into “cultural models” — preconceived notions about the way the world works — when processing information about important social issues such as patient safety. Frameworks found that members of the public commonly believe that the best way to prevent adverse outcomes in health care is to choose “a caring doctor,” an idea shared by clinicians who believe that their individual caring and skills are what keep their patients safe.

These ways of thinking undoubtedly factored into the prosecution’s pursuit of criminal charges against Vaught and the jury’s decision to convict her – a jury of peers that included a nurse and two respiratory therapists who work in hospital settings. Looking beyond this particular case, the dominant cultural models of individual capability and culpability for medical errors will be barriers to building support for investments in the structures and processes that can catch mistakes before they harm patients. Indeed, another key FrameWorks finding was that clinicians and the public share a skepticism or even antipathy toward exactly the kinds of systems improvement strategies favored by safety experts.

So, what can we do?

There are a number of evidence-based communication strategies to use: connecting the dots between causes and solutions, better defining terms like “patient safety” and “medical error” and keeping the whole picture of patient safety at the forefront of conversations rather than focusing too narrowly on one cause or one solution.

More important, however, will be for Massachusetts to invest in systemic improvements that have the potential to transform health care safety. The Massachusetts Healthcare Safety and Quality Consortium, a public-private partnership of almost 40 stakeholder organizations and state agencies, has produced a Roadmap to Healthcare Safety that lays out a framework for achieving ambitious goals for eliminating preventable patient harm across the continuum of care. Currently, four task forces are crafting programmatic and policy recommendations and action steps for advancing the Roadmap’s goals in the short and long term.

Surely one measure of success will be an end to punitive, finger-pointing exercises in favor of effective, systems-based efforts to eradicate preventable medical harm.

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Email us your feedback and comments: PatientSafetyBeat@BetsyLehmanCenterMA.gov