Catch and Correct

Published in Hopkins Medicine - Summer 2020

Patient safety exploded into public consciousness on Nov. 29, 1999, when two popular evening TV newscasts made their top story a leaked report from the National Academy of Sciences’ Institute of Medicine. The study — To Err Is Human — argued that medical errors were a significant factor in American mortality.

News of the report reached more than 100 million people within a week, and the uproar spurred a frenzy of proposals for patient safety reform, including calls for a 50 percent reduction in medical error. Yet two decades later, Kathleen M. Sutcliffe says, those reforms are now “becalmed,” and medical errors remain a leading cause of death in the United States.

How reform stalled is the subject of her new book, Still Not Safe: Patient Safety and the Middle-Managing of American Medicine, which was co-authored with Robert L. Wears. An alumnus of both The Johns Hopkins University and its school of medicine, Wears died in 2017, shortly after the manuscript was finished.

Still Not Safe is a comprehensive history of patient safety. Yet is also offers a call for substantive improvements through collaborations that draw deeply from the expertise of both physicians and researchers.

The book itself models such collaboration. Sutcliffe is a Bloomberg Distinguished Professor of Medicine and Business at Johns Hopkins, and her research focuses on organizational theory, while Wears was a physician and a professor at the University of Florida College of Medicine – Jacksonville, specializing in emergency medicine.

The authors note that over the past 20 years, the health care industry’s obsession with costs and desire for control has slowed reform efforts, yet “dramatic and poignant accounts of medical harm” in popular media keep the issue in the spotlight. Sutcliffe and Wears identify competing narratives about patient safety from physicians and researchers as the heart of the problem.

“There hasn’t been enough effort to be more systematic,” observes Sutcliffe, “and to develop interdisciplinary expertise and sustained partnerships. Interdisciplinarity is really tough to do. People speak different languages.” The authors note that fundamental reform will require “substantive and equal co-partnerships with safety scientists.”

As an example of how safety science can make a difference, Sutcliffe points to how advances in surgical procedures have not always registered across institutions.

“Surgical mortality rates vary widely,” she observes. “Most people would say, ‘Well, it’s complication rates.’ But high- and low-mortality hospitals have the same rates of complications. What’s different in low-mortality hospitals is something called ‘the ability to rescue.’ High-mortality hospitals are ‘failing to rescue.’”

Organizational studies can identify best practices in such rescues. “What kinds of daily habits do people engage in?” asks Sutcliffe. “What do they do in order to be more alert and aware about what’s happening in the context in which they’re working?”

Sutcliffe — who also holds an appointment at Johns Hopkins’ Armstrong Institute for Patient Safety and Quality — says better collaborations between physicians and safety researchers aim to identify not only failure but also ways to bounce back from it, with evidence-based strategies that can be promulgated and widely adopted across the industry.

“We need to understand our failures,” she observes, “because it gives us a sense about the health of our systems, right? So that’s critical. But we also need to acknowledge the fact that in the course of doing work, people are constantly making mistakes. And they’re catching them and correcting them.

“Basically,” concludes Sutcliffe, “we need to understand what we can do to help people be more resilient in the moment. To be able to adapt and catch and correct better. We need to understand both how things are going right — and how they go wrong.”