Viewpoint: Improving Patient Safety Is Our Responsibility

By Richard H. Dean, M.D. President, Wake Forest University Health Sciences

As I reflect on the powerful recent reports published by the Institute of Medicine (IOM) regarding the quality of medical care in the United States and read the countless articles and editorials attesting to the accuracy of the reports condemning our medical system's errors, I have to ask: Where were we when the data was collected on which the current findings are based? How successful has the leadership of academic medicine been as spokespersons for quality, as advocates for patient safety and as architects of change?

Clearly, the initial response from the academic medicine community to the IOM reports was that any suggestion that errors in treatment occurred must be based on flawed data or that such errors were a rarity. As the dust has settled, however, and we evaluate our own medical care delivery systems, we find evidence of delays in medication delivery, the wide gap in recognition and response time from physicians and nurses, the lack of compliance with fairly basic standards of sterility and patient medication errors to be systemic rather than the exception we all proclaimed. The indisputable message is that the frequency of avoidable errors in our hospitals and other health care delivery systems is unacceptable. We all must implement changes to enhance patient safety.

Computerized patient order entry, bar coding to track accuracy of medication delivery and use of PDAs and bedside laptop computers to standardize care and diminish human error should all become standard practice. Although the cost of implementing these measures may be staggering, the benefits to patient safety are indisputable and such measures must be initiated at sites delivering complex care, especially in our nation's academic medical centers.

Independent of changes that were recommended by the IOM, there are ongoing shifts in how care is delivered in academic medical centers. Think for a moment about how care was delivered only a few decades ago. Patients were treated by resident physicians working up to 120 hours per week with relatively loose professorial supervision. Certainly, the historical trial-by-fire mechanisms of resident education have diminished in recent years as the teaching faculty took a more active role in supervising residents. But many other changes, such as reductions in resident duty hours remained relatively unchanged until legislative actions and public demands forced us to take action.

Further, most academic medical centers, in an effort to compete with other local providers for market share, now advertise themselves to prospective patients as sites with professional expertise not available elsewhere in the market. At many academic medical centers, however, care is still driven by historical algorithms of student and resident education in which the attending faculty provider remains an on-call consultant to the frontline care providers, the team of resident physicians. My point is that we, more often than not, have been the defenders of the status quo rather than the protagonists for system-wide change.

Without question, our system of medical care and our academic medical centers have many virtues and have spawned most of the advances in modern medicine. Nevertheless, the clinical medical education of our students and physicians-in-training has frequently evolved in response to external forces and demands for change rather than through conscious internal transformation with patient advocacy as a core principle. Indeed, the current system of graduate medical education is driven more by traditional approaches to workforce needs within academic medical centers than by responses to broader, national physician needs or by a self-enlightened system of education.

The roles of nurses, physician assistants, other allied health care professionals and physicians continue to evolve. As leaders of academic medicine, it is imperative that we embrace these needs for change and pursue new paths that incorporate the roles of all such professions in an integrated, patient-centered approach while also redefining the role of graduate medical education in care delivery. Although resident physicians should continue to play an important role in patient care, they cannot continue to be the front-line service providers with attending back-up when the patient expects at least equal involvement by his or her attending physician.

Whether we expand the role of the hospitalist for in-patient teaching services or revive the ward service, we must align the system of education and the oversight of students and residents with the presumed contract and expectations of the patients that we serve. Without the necessary engagement and the willingness to change, we risk losing the trust of patients who look to us in their time of greatest need.

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