Institute of Medicine report
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* Jonathan L. Meakins

Late in 1999 a publication by the United States Institute of Medicine (IOM) caused a stir in the press worldwide. The publication was titled “To err is human — building a safer health system.” All communication systems focussed on the reported data that in the US there were at least 44 000 deaths every year from medical error and that, on the basis of published data, this number might be as high as 98 000. If we assume that Canada has approximately 10% of the problems and advantages of the US, then 4400 to 9800 deaths per year may be associated with errors in health care delivery.

Although we all recognize the possibility and the untoward results of error in medicine, these data seem overwhelming. However, given the under-funded state of our system, it is unlikely that we are doing any better than our neighbours. The level of disbelief among administrators and the health care profession must be addressed. Accepting that there is a real level of morbidity and mortality from errors of some sort (professional, systemic, administrative) would be the first step to improving outcomes. Acknowledging that we have a problem and developing and implementing short- and long-term strategies to correct this state of affairs seems to be the most appropriate approach.

The IOM report has 4 tiers of recommendations. The first 2 involve legislation, regulations and mandatory reporting. Mandatory reporting, of course, creates fear among health care professionals. But the third and fourth tiers address what health care organizations, professional groups and accrediting bodies can do to raise standards of patient health and create a safe delivery system.

What might surgeons look to in the near and long term? As an example, how many of our operating rooms have a form relating to the SIDE of a surgical procedure? If a paired organ is to be operated on or resected, confirmation, signed in the operating room by nurse, surgeon, patient and anesthetist, of the side should be obligatory to ensure that the correct leg, hernia or kidney is operated on. This seems so obvious but is difficult to implement.

Other short-term approaches would include clinical protocols, pathways and care maps to standardize common procedures, eliminate variation and reduce the potential for error. Although this decreases the autonomy of individual physicians, it is unlikely that individual likes and dislikes on little details are important in patient-centred management.

Over the long term, education in medical school, through residency and at the CME level must stress the continuous quality improvement that the Royal College of Physicians and Surgeons of Canada expects, through the maintenance of competence and focus on safety in health care delivery systems. Clearly, government and CEOs must put money into the system to facilitate and support the development of attitudes associated with patient safety. Communication, both vertical and horizontal, is an important component of patient safety and needs to become an integral part of our culture. Vertical communication is the senior surgeon’s ability to listen to colleagues and juniors when they have a suggestion for change that differs from the hierarchy, whereas horizontal communication takes place between physicians, nurses, physiotherapists, administrators, and so on.

Society needs to make the correction of errors in medicine a reward function rather than a punishment function, which is the present state of affairs. This approach applies as much to health care organizations as to Society at large. In addition, within the surgical domain, creative links with industry with respect to the use of new instruments and new technology can heighten awareness of safety issues in the delivery of care to patients.

The Journal looks forward to communication with its readers on how the broad community of surgery can best approach these problems in a proactive rather than in a reactive manner.