To Do No Harm: Safety as a Professional Obligation

I emphasize these points not to provide a history lesson, but because of the growing concern I have that safety is not yet on a par with other medical precepts like surgical technique or confidentiality.

How often have we heard the line “the surgery was successful but that the patient died?” Such deaths are not always attributable to errors in the operating room, but to post-operative infections, medical errors, and problems at home due to poor discharge instructions or lack of proper follow-up care.

To back this up, let me offer just one statistic, the consensus is that nearly 100,000 Americans are losing their lives each year in hospitals due to medical errors and many more are harmed by infections and medication-induced complications. Sadly, these deaths and injuries were avoidable. Can we prevent them in the future? Yes, I believe we can. As Chief Medical Officer for the Blue Cross and Blue Shield Association, I am constantly meeting and discussing with fellow physicians and providers the need to make care safer, more patient focused and more affordable.

But of these three, SAFETY is paramount.

Not a day goes by when my email doesn’t have a product recall or another example of medical practice “gone bad” as a result of poor judgment or carelessness. 

An example of that recently appeared in the New England Journal of Medicine, which highlighted the misuse of diagnostic imaging tests -- providing as evidence the story of a 59 year old schoolteacher who received 100 times the average radiation dose during a brain CT. A test it turns out, that was not even necessary if the patient’s condition would have been properly diagnosed.

All of which points to the fact that we must never discount such common sense safety measures such as tracking radiation exposure or making imaging equipment safer.  

So what can we specifically do to focus more attention on improving patient safety?

Let’s first start by educating hospital boards, with the aim of encouraging them to become more engaged in adopting a number of processes including system level harm measurements that would directly improve the safety of patients.

It’s time we get the “boards on board” for quality care and safety issues. After all, responsibility for safety in hospitals lies, in part, on each institution’s board of directors.  This is actually the name of a program created by the Institute for Healthcare Improvement (IHI) to educate and engage hospital boards. In far too many cases, the responsibility of safety and quality concerns has been delegated by the board to the medical staff.

That’s why I’m encouraged by IHI’s initiative to have all hospital’s boards spend at least 25 percent of their meeting time on quality and safety issues. Equally important, there is the further goal that the boards have a conversation with at least one patient (or family member of a patient) who sustained serious harm within the last year at their institution.

Moving from the hospital board room to the surgical unit, pre-operation check lists can also help save lives. Simply by calling a time-out prior to making a skin incision in the operating room, and specifically going over the procedure to be done and the instruments to be used, could have a dramatic effect. Complications fall dramatically and outcomes improve significantly when this simple step, as endorsed by the World Health Organization, is taken by the surgical team. 

Then there are the ever present medication complications that are all too frequently encountered in a hospital setting, including improperly administered dosages. But this problem can arise even in a patient’s own home. The total number of drugs sitting on a patient’s kitchen table or bathroom shelf can be at times overwhelming, and the prescriptions baffling, to the patient or their family members.  

Most chronically ill patients, for example, see many different doctors in multiple clinics, none of whom know what the others have prescribed.  Patients look at the line-up of prescription bottles and are befuddled. Either taking too many (with adverse drug reactions occurring) or giving up, and taking none. Readmissions, preventable illness, and occasionally far more serious events (kidney failure) unfortunately can result. 

Clearly, we need somebody on the care team, a primary care doctor would be the ideal candidate, to take charge of this pharmaceutical alphabet soup and carefully direct a patient’s exposure to drugs -- seeking to maximize the benefit while minimizing the harm. 

The loss of life and damage to health is too great for us to wait. Now is the time to act and make safety the cornerstone of 21 century medical practice.  

Allan Korn, M.D., is Chief Medical Officer and Senior Vice President for Clinical Affairs for the Blue Cross and Blue Shield Association (BCBSA), a national federation of 39 independent, community-based and locally operated Blue Cross and Blue Shield companies.