Patient Safety and Health Care

The fact that "patient safety" is a relatively recent initiative in health care is nothing short of shocking. Emphasizing the reporting, analysis and prevention of medical errors and adverse events should be inherent in the system that patients rely on for care. However, the frequency and magnitude of avoidable adverse events was not generally acknowledged or discussed until the late 1990s, when reports in several countries revealed a staggering number of patient injuries and deaths each year.

A decade later, patient safety initiatives and quality improvements abound. The problem is these are generally desperate attempts to place band-aids on systemic problems. These random acts of quality and safety can do more damage than good when applied haphazardly or piecemeal in an organization.

Patient safety and quality initiatives that are being adopted today include the application of lessons learned from business and industry, implementation of advancing technologies, education of providers and the public, and economic incentives for providers and facilities. While well intentioned, these programs must build on a common foundation that is often lacking in health care organization.

The foundation that is needed, regardless of initiative, is an effective strategy that embraces and hardwires effective teamwork and communication.

One of the best practices in creating teams that perform and communicate reliably in critical situations is Crew Resource Management (CRM). This training methodology used by the commercial aviation industry hard wires the skills and techniques needed to successfully build a culture of quality and safety on a platform of collaboration. CRM skill development, coupled with routine and frequent error and incident reporting, has helped transform commercial aviation into a model of high reliability operating well beyond a level of six sigma quality and safety.