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Patient Safety: 54 Years Of Progress ... or Stasis?
Leadership and culture change are needed to turn the tide.
Kenneth Rothfield
Publish Date: May 25, 2016
OR Excellence
Kenneth P. Rothfield, MD, MBA, CPE, CPPS Kenneth P. Rothfield,

Speaker Profile

  • Member of Physician- Patient Alliance for Health & Safety board of advisors.
  • Member of Ascension Health's High Reliability Steering Committee.
  • Earned ?Maryland Patient Safety Center's "Circle of Honor Award for Innovation in Patient Safety."

It's disheartening, says anesthesiologist and patient safety expert Kenneth P. Rothfield, MD, MBA, CPE, CPPS, how little patient safety has improved during his lifetime. More than 400,000 U.S. patients die from preventable medical errors each year. Only heart disease and cancer kill more Americans. In Dr. Rothfield's presentation, "Patient Safety: 54 Years of Progress or Stasis?" he'll plot the progress — or lack thereof — that's been made on a 5-decade timeline and challenge you to eliminate the never events that keep happening.

  • The human element. Try as we might to create systems that are infallible, there are really no human-proof systems in health care. We have to rely on the vigilance of providers who may unwittingly make errors. We also have people who make decisions to bypass policies, procedures and rules that are in place to keep patients safe. They're not trying to hurt anybody, but they engage in risky behavior. And sometimes people are just reckless — though fortunately not very often. But it happens and our patients pay the price for it.
  • The importance of culture. As much as we'd like a magic bullet for many of these challenges, the solutions are cultural and social, not technical. For example, there was a lot of excitement about implementing checklists a couple of years ago, but we continue to have issues. Why? Because it's really a function of culture and leadership that make checklists work. As a theory, it sounds great, but the implementation is much trickier. It involves changing the way people interact and the way they feel about their work.
  • Leadership needed. We need to switch from a craft model in which doctors are completely autonomous to having doctors understand that they're part of a team, and that what other people do is just as important as what they do. I always say that the person taking out the trash is just as important as the person taking out the gallbladder. But that's not the kind of social construct our hospitals have developed.
  • Sea change for physicians. For a lot of doctors, quality and safety are someone else's job. Doctors are raised on a steady diet of autonomy, hierarchy and competition. It's a sea change to be told to think of yourself as a member of a team, and that you should implement best practices that have been developed by other people, especially when what you're doing seems to be working just fine. But it won't be until we get to that level of standardization that we're going to make a difference. Every other industry has figured out that variation yields terrible results.
  • Learning how to lead. To turn the tide with patient safety, we need physicians to get more training and learn how to be effective leaders. We're inclined to put them in leadership positions, but the reality is that leadership usually isn't something you're born with. Its something you learn. It's being able to share that vision and get people to come along willingly. It's not about using authority to compel people to do things.
  • Full responsibility. The tipping point will be when healthcare organizations take full risk for their outcomes — when outcomes determine what they get paid. That's happening now in a small way around the CMS penalties for outcomes, but it won't be until every penny is at risk for safety and quality that organizations will get 100% behind making quality job one. OSM