Earlier in my life, before I started my training to become a physician, before I even knew I wanted to be a doctor, back when I still considered pursuing a graduate degree in history, I viewed hospitals in the same way the average American does – an extremely safe place. Yes, many individuals may spend their last days in a hospital, but they are receiving the best care possible. Yes, modern medicine is not a panacea, but individuals, for the most part, do not go to the hospital to get sicker. If they do, it is a result of their disease process’ ability to continue to progress despite the staff’s best intentions and efforts. Even at that point in my life, however, I was not naive enough to think that mistakes never happen, but I believed that the rate of these mistakes had to be exceedingly low – after all these are highly trained healthcare practitioners practicing in modern hospitals with the latest equipment and training.
Once I realized that my career path pointed toward medicine I, on the advice of a more seasoned colleague, investigated the Institute for Healthcare Improvement (IHI) and participated in their Open School – a series of modules designed to educate the healthcare professional on quality improvement and patient safety theory and practice. I was shocked to hear about how unsafe hospitals are for patients. A striking statistic that was repeatedly mentioned during the modules, and again in both Why Hospitals Should Fly (WHSF) by John Nance and Wall of Silence by Rosemary Gibson and Janardan Prasad Singh, was the Institute of Medicines 1999 startling document, titled to Err is Human, that approximately 100,000 (the upper bound of the estimate) Americans die annually from medical errors.
I was confused. How could highly trained and dedicated professional cause so much harm? How could such selective and rigorous education processes that are present in the US lead to individuals who commit so many mistakes? What the modules went on to argue, as did WHSF, was that in most cases processes and systems, not individuals, fail. They do so by putting individuals in situations where mistakes can easily occur, or they allow errors because they are not structured in a way to catch mistakes and prevent harm. The fact that professionals are usually not the root cause of errors is reassuring. Processes can be changed or optimized, thereby reducing errors and increasing the quality of care. However, as I move forward in my training, I have learned that the sheer inertia of the healthcare system – the inertia of ‘This is how we have always done it,’ or ‘We are doing better than the national average, is that not enough? – can impede the desire for improvement.
My experience in QI and patient safety improvement centers on my home institution, University of North Carolina Hospitals, which I feel is a progressive institution. It was the openness of UNC to QI and patient safety projects, championed by both the medical school and UNC’s Institute of Healthcare Quality Improvement, that made me interested in participating in the Telluride Experience (TTE). The proverbial icing on the cake is the glowing endorsement of TTE by other UNC students and professionals that have previously been through the program. I hope that through my experiences at TTE and continued involvement in QI and patient safety at UNC and beyond I will be able to help reduce medical mistakes and improve the quality and value of care for patients. I am certainly excited to learn and experience more, and I cannot wait to jump in with both feet in the next few days.