An executive in the airline industry once told me that airlines don’t advertise their safety records
because it reminds people that errors and airplane accidents can occur. If there was once a time when people were unaware that errors can occur in healthcare, that time is long gone.
In 1999 the Institute of Medicine released its report, To Err is Human: Building a Safer Health System. It included alarming estimates on the impact of medical errors on our health and risk of mortality. The report received enormous media coverage and created demand for significant improvements at all levels of healthcare. Federal and state agencies responded with increased oversight and regulatory requirements that continue today.
But the greatest changes have taken place in healthcare organizations. All healthcare professionals are trained to be individually responsible for their actions and decisions. If a physician, nurse, or other professional made a mistake, the fault was attributed primarily to that individual. By citing multiple studies, the IOM showed that while human beings can make errors, flaws in the systems they rely on can increase their risk of making them.
Since then, hospitals and other organizations have made huge strides in the redesign of equipment and work processes to make their systems of care as safe as possible. “Time-out” pauses require providers and teams to double-check critical details before every procedure. Information systems are designed to ensure correct medication orders and administration to the correct patient. Redundant communications when a patient is moved help maintain accurate continuity of care. All staff can freely report a safety concern to improve processes and help to further improve safety. Doctors and nurses are still trained for individual competence but expect to function as members of a system of care.
The term “healthcare” tends to be associated with maintaining wellness. It understates the complexity of managing chronic diseases and treating acute and life-threatening illnesses, which often occur in people suffering from several at once. Providing safe care that requires multiple experts, technical skills, constant monitoring and response to rapidly changing conditions, and coordination of all those efforts depends on having safe systems. In 2020, two decades of system development has helped us respond to the most severe disease challenge in our lifetime.
When COVID-19 first appeared, the impression was that of a respiratory infection similar to influenza but with greater capability of becoming severe and potentially fatal. It quickly demonstrated its extreme infectivity in a highly mobile global population that had no prior immune response to it. It also proved to be more than a respiratory pathogen as it variably injured people’s digestive tracts, hearts, kidneys, blood clotting function, and nervous systems. Older people and those with major chronic diseases are more vulnerable, but it tragically and unpredictably takes some young healthy people as well.
Providers, nursing facilities, and hospitals struggled to figure out the most effective treatments for a disease they’d never encountered. Treatment regimens that worked for other severe viral infections were sometimes ineffective and had to be replaced by medications and approaches to care developed on the fly. Hospitals, after decades of pressure to reduce costs, did not have pre-existing surge capacity adequate to manage the sheer volume of seriously ill COVID patients. They rapidly repurposed their facilities and staffs to accommodate those needs while still providing care and safety for non-COVID patients. Providers and staff were themselves at risk for becoming infected as global supplies of personal protective equipment ran short. Federal emergency planning was aimed at regional disaster support and could not assist virtually every region in the country simultaneously.
Little has been said about the impact that safe patient care systems have had on our ability to take on this crisis. It’s hard to imagine a scenario more likely to overwhelm our healthcare resources. The potential for a widespread breakdown of healthcare was real. Certainly there were areas that were overwhelmed at times, but there has been no overall failure. Our strained hospitals have been able to and continue to provide acute care through the pandemic.
To do this, hospitals and providers employed their clinical skills plus principles of system safety. Some, such as negative air pressure and construction to separate COVID and non-COVID patients, were specific to a respiratory virus spread by airborne droplets. Others were processes developed over twenty years of focus on patient safety. A novel disease requiring new approaches to patient care invites multiple errors. Very few happened, thanks to the foundations of safety already in place.
Many people have not perceived this. Hospitals and emergency departments across the U.S. experienced a sharp decline in patient volumes for non-COVID conditions. Surveys showed that fear of contracting COVID in hospitals caused people to stay away, sometimes allowing their medical problems to progress. We are now seeing reports of increased mortality rates for chronic conditions such as heart failure and coronary artery disease that may have been the result. Fortunately, E.D. visits for those illnesses appear to be coming back toward normal levels now.
Unfortunately, the pandemic continues and may surge again. No one knows how soon a vaccine may be available, and no cure exists yet. But we know a lot more about COVID-19 now than we did six months ago. We know what treatments can reduce the severity and the risk of mortality. New information and new treatment options continue to be developed. Our resources and our capacity to respond to a surge have significantly improved. Patient safety can always be improved upon, and new methods will continue to be developed and shared. But we already know a lot about keeping patients safe if they need us, for COVID-19 or non-COVID illnesses.
About Dr. Joseph Moser
Dr. Joseph Moser is the Chief Medical Officer at University of Maryland Charles Regional Medical Center. He has over 40 years of experience in the healthcare field and now oversees all of UM Charles Regional Medical Center’s doctors on staff.