Despite decades of effort, the healthcare industry has failed to achieve meaningful progress in patient safety goals, according to Emergency Care Research Institute President and CEO Marcus Schabacker, MD, PhD.
"We still see alarming rates of preventable harm," Dr. Schabacker said in an Oct. 17 post, citing a 2023 study that found about 23% of adverse events were preventable.
Eliminating the "four greatest weaknesses in the American healthcare system" will mitigate nearly all safety hazards in healthcare, he said. These weaknesses are:
1. Neglecting systems-based solutions
Medical errors are too often viewed in isolation, he said, adding that patient harm cannot be attributed to a single point, process or person.
"Too many industry leaders approach healthcare as a purely social system — but you cannot ensure safe care through training and workforce education alone," Dr. Schabacker said. "Healthcare is a complex socio-technical system where the physical environment, tasks and processes, tools and technology, the overarching organization, its people, the patients and their caregivers, and the external environment are inextricably linked."
2. Overlooking human factors engineering
Systems should work for people, rather than the other way around, he said.
Human factors engineering involves understanding how a system's design can lead to human error. For example, the solution to infusion pump programming errors could be redesigning an EHR screen layout.
While it is impossible to fully remove human error from healthcare, it is possible to minimize its frequency and impact.
3. Stifling 'just culture' in the workforce
A blame culture — where frontline staff are not empowered to speak up about issues — manifests into a cycle of preventable errors.
Dr. Schabacker said healthcare organizations should encourage and reward those who report mistakes, near misses and safety concerns.
4. Ignoring health inequities
Disparities are not accidents, Dr. Schabacker said, "they are the result of explicit and implicit bias, and systemic failures that prioritize profit over people."
"No clinician goes into work and intentionally chooses to treat a patient differently based on their background. Yet it happens every day," he said. "Even the technologies and tools we use to deliver care can fuel inequitable outcomes. We cannot solve a problem that people don't believe exists — so it starts with awareness within our institutions and self-awareness among clinicians, that health inequities are real, pervasive and catastrophic."