A friend of mine once said that Dr. Peter Pronovost deserves a Nobel Prize for the work he has done to improve patient safety and reduce harm. Of course, that won't happen because the Nobel Committee does not recognize lives saved through process improvement. (Hmm, maybe someone could start a prize for that.)
The latest contribution is an article in JAMA today entitled, "Learning Accountability for Patient Outcomes." An excerpt*:
Each year, an estimated 100 000 patients die of health care–associated infections, another 44 000 to 98 000 die of other preventable errors, and tens of thousands more die of diagnostic errors or failure to receive recommended therapies. Physicians are overconfident about the quality of care they provide, believing things will go right rather than wrong, assuming they provide higher-quality care than the evidence suggests, and thinking they alone have sufficient knowledge and skills to provide care. Teamwork failures are common contributors to harmful errors. In many cases, someone knew something was wrong and either did not speak up or spoke up and was ignored. It is unclear how many teamwork and communication failures result from arrogance. Most clinicians have personal stories of arrogance causing patient harm.
I have seen two responses among physicians to the things Peter says and does. One reaction is resentment and anger -- ironically often proving thereby the very points he has raised. The other is a respectful recognition and acceptance and desire to learn and improve.
Kudos to Peter for willing to take the heat from those in his own profession for saying the things that need to be said. It cannot be a lot of fun.
Kudos, too, to those in the profession who have taken his lessons to heart and are saving lives every day. They are the ones who provide the "Kevlar" vest, offering Peter the protection of actual clinical outcomes that prove his worth every single day.
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*Wouldn't you love to read the whole thing? Maybe, someday this influential journal will understand that it would be still more influential if it permitted free access to articles of public import like this.
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