In the wake of three tragic deaths at Children’s Hospital Boston, the issue of patient safety has once again made national headlines.
These events painfully highlight the shortcomings in our existing health care system — skilled and caring physicians do make mistakes, primarily due to errors in protocols and in methods of communication, often involving complex conditions.
This sentiment is supported by the Institute of Medicine in its landmark 1999 study of medical errors.
“The majority of medical errors do not result from individual recklessness or the actions of a particular group,” the report states. “More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them.”
Unfortunately, the current regulatory and legislative climate does not support positive incentives to promote enhanced safety and error prevention.
Despite these ongoing challenges, the Mass. Medical Society diligently continues to champion the cause of patient safety.
It is the position of the MMS to promote a new system design that makes it difficult to do the wrong thing and easy to do the right thing. This can be encouraged by allowing professionals to re-engineer the workflow in patient care settings, while working to eliminate the current culture of ‘shame, blame, and finger-pointing.’
Reporting errors and analyzing the best way to change habits should be our goal, as long as the reporting is designed to be confidential, yet accountable and productive of meaningful change. We can learn from other industries about how to use confidential error reporting to discover and correct our system-related problems.
For many years, the MMS has pursued specific and broad-based initiatives to promote safety within health care.
In 2002, for example, the state Board of Registration in Medicine endorsed guidelines developed by the MMS to govern office-based surgery, including the recommended qualification of practitioners and staff, equipment, facilities, and policies and procedures for patient assessment and monitoring.
The Mass. Medical Society also has adopted and is encouraging the use of a list of abbreviations not to use, developed by the Institute for Safe Medication Practices. These abbreviations are often misinterpreted and can be a source of potential patient safety problems.
Most recently, the MMS designed a unique and comprehensive online curriculum to educate physicians on ways to illustrate the scope and magnitude of medical errors and the information available on the nature, distribution, prevention, and control of medical errors.
The MMS is committed to system change through confidential reporting and system redesign. It is our hope that lawmakers and industry stakeholders will join us in this vision.
Thomas E. Sullivan, M.D. is president of the Mass. Medical Soviety. Founded in 1781, the MMS is the oldest continuously operating medical society in the United States. Today, with more than 18,000 members, the society advocates for physicians and patients, while assuming a leadership role in public health, health system reform, and the quality of health care and patient safety.