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3 May 2005 | Volume 142 Issue 9 | Pages 756-764
Although debate continues over estimates of the amount of preventable medical harm that occurs in health care, there seems to be a consensus that health care is not as safe and reliable as it might be. It is often assumed that copying and adapting the success stories of nonmedical industries, such as civil aviation and nuclear power, will make medicine as safe as these industries. However, the solution is not that simple. This article explains why a benchmarking approach to safety in high-risk industries is needed to help translate lessons so that they are usable and long lasting in health care. The most important difference among industries lies not so much in the pertinent safety toolkit, which is similar for most industries, but in an industry's willingness to abandon historical and cultural precedents and beliefs that are linked to performance and autonomy, in a constant drive toward a culture of safety. Five successive systemic barriers currently prevent health care from becoming an ultrasafe industrial system: the need to limit the discretion of workers, the need to reduce worker autonomy, the need to make the transition from a craftsmanship mindset to that of equivalent actors, the need for system-level (senior leadership) arbitration to optimize safety strategies, and the need for simplification. Finally, health care must overcome 3 unique problems: a wide range of risk among medical specialties, difficulty in defining medical error, and various structural constraints (such as public demand, teaching role, and chronic shortage of staff). Without such a framework to guide development, ongoing efforts to improve safety by adopting the safety strategies of other industries may yield reduced dividends. Rapid progress is possible only if the health care industry is willing to address these structural constraints needed to overcome the 5 barriers to ultrasafe performance.
Author and Article Information
From the Cognitive Science Department, Brétigny-sur-Orge, France; Percy Military Hospital, Paris-Clamart, France; Institute for Healthcare Improvement, Cambridge, Massachusetts; and Jackson Memorial Hospital and Miami Center for Patient Safety, University of Miami Medical School, Miami, Florida.
Acknowledgments: The authors thank Frank Davidoff, Jane Rossner, and Marshall Gilula for editorial review and helpful suggestions.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Paul Barach, MD, MPH, University of Miami Medical School, North Wing 109, 1611 Northwest 12th Avenue, Miami, FL 33136; e-mail, pbarach{at}med.miami.edu.
Current Author Addresses: Dr. Amalberti: Département sciences cognitives, IMASSA, BP 73, 91223 Brétigny-sur-Orge, France.
Dr. Auroy: Hôpital Percy, Service d'Anesthésie-réanimation, 101 Avenue Henry Barbusse, 92141 Clamart Cedex, France.
Dr. Berwick: Institute for Healthcare Improvement, 20 University Road, 7th Floor, Cambridge, MA 02138.
Dr. Barach: University of Miami Medical School, North Wing 109, 1611 Northwest 12th Avenue, Miami, FL 33136. IMPROVING PATIENT CARE
PATIENT SAFETY AND THE RELIABILITY OF HEALTH CARE SYSTEMS
Series Editors: Paul Barach, MD, MPH, and Donald M. Berwick, MD, MPP
Improving Patient Care is a special section within Annals supported in part by the U.S. Department of Health and Human Services (HHS) Agency for Healthcare Research and Quality (AHRQ). The opinions expressed in this article are those of the authors and do not represent the position or endorsement of AHRQ or HHS.
Five System Barriers to Achieving Ultrasafe Health Care
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