Where things stand . . . and what comes next.

A recent article by Bob Wachter, Peter Pronovost and Paul Shekelle in the Annals of Internal Medicine gives a helpful update about the state of efforts to improve patient safety.  These are people who know of what they speak, as researchers, practitioners, teachers, and observers.  (I count them among my best teachers, by the way.)

Read the whole thing, but note this conclusion:

A decade ago, our early enthusiasm for patient safety was accompanied by a hope, and some magical thinking, that finding solutions to medical errors would be relatively straightforward. It was believed that by simply adopting some techniques drawn from aviation and other “safe industries,” building strong information technology systems, and improving safety culture, patients would immediately be safer in hospitals and clinics everywhere. We now appreciate the naivety of this point of view. Making patients safe requires ongoing efforts to improve practices, training, information technology, and culture. It requires that senior leaders supply resources and leadership while simultaneously promoting engagement and innovation by frontline clinicians. It will depend on a strong policy environment that creates appropriate incentives for safety while avoiding an overly rigid, prescriptive atmosphere that could sap providers' enthusiasm and creativity.

Well put, I think.  I'd like to go a step further, though, with an addendum that reflects my experience as CEO of a hospital.  An effective patient safety program requires that a hospital become a learning organization.  As the folks at Cincinnati Children's Hospital put it years ago, "We want to be the best at getting better."  A learning organization is one in which all members of the staff, not just frontline clinicians, participate in process improvement.  In our hospital, we often found that it was the housekeepers, food service workers, security guards, supply folks, and transporters who noticed and called out important problems in the delivery of care.  Bob and Peter and Paul didn't mention these non-clinicians in their summary.  I don't think they would disagree with me, though, and I respectfully offer this addendum with the hope that all of us remember to explicitly include them as we think about what should come next.