Organizational Safety
Over the last few years there have been many landmark publications
and activities concerning to patient safety and the organizational aspects of reducing
errors.[2]
[3]
[57]
[58]
[59]
[289]
[290]
[291]
The
report of the Institute of Medicine (IOM) in 1999, "To Err Is Human,"[3]
was a highly publicized awakening in the United States about the problems of patient
safety. Summarizing the primary literature, the report stated that "tens of thousands
die each year from errors in their care and hundreds of thousands suffer or barely
escape from nonfatal injuries that a truly high-quality care system would largely
prevent." The most important recommendations of this report, which led to nationwide
activities to promote patient safety, are shown in Table
83-10
.
TABLE 83-10 -- Recommendations of the IOM report "To Err Is Human"
|
• Make patient safety a declared and serious aim. |
|
• Provide strong, clear, and visible attention to safety. |
|
• Implement non-punitive systems for reporting and analyzing
errors (see Table 83-15
). |
|
• Incorporate well-understood safety principles, such as
standardizing and simplifying equipment, supplies, and processes. |
|
• Establish interdisciplinary programs to improve teamwork
and communication using modalities proven in other industries, including simulation. |
|
IOM, Institute of Medicine. |
The subsequent report of the IOM Committee on Quality of Health
Care in America, entitled "Crossing the Quality Chasm—A New Health System for
the 21st Century,"[57]
took a systematic approach
to the improvement of the entire health care system. It stated that "between the
healthcare we have and the care we could have, lies not just a gap, but a chasm,"
because the health care system today harms too frequently yet routinely fails to
deliver its potential benefits. The report concluded: "The current care system
cannot do the job. Trying harder will not work. Changing the systems of care will."
In the following section we consider the organizational and systems aspects of anesthesia
care and patient safety.
There are several schools of thought about organizational safety
in high hazard activities. Two theories, normal accidents theory (NAT) and high
reliability organization theory (HROT), have dominated the discussion of safety in
many domains and have been applied individually to health care with increasing frequency
over the last 15 years.[64]
[67]
[201]
[204]
[288]
[289]
[290]
[291]
[292]
NAT was originally promulgated by the sociologist
Charles Perrow[146]
[293]
[294]
in the wake of the Three Mile Island nuclear
accident and has been applied by him and others to such diverse fields as commercial
aviation, maritime transport, and the handling of nuclear weapons.[295]
HROT was promulgated initially by a group of researchers at the University of California
at Berkeley.[296]
[297]
[298]
[299]
[300]
[301]
It has also been applied to diverse domains,
[302]
including aircraft carrier flight decks, offshore
oil platforms,[303]
air traffic control, nuclear
power production,[304]
[305]
and the financial transaction industry (personal communication, Karlene Roberts).
These workers' complementary views of organizational safety[295]
are summarized briefly here and in Table
83-11
.
