Lucian L. Leape - Making Healthcare Safe: The Story of the Patient Safety Movement

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I guess we all live history in some sense. But, for some of us, that phrase has a more specific meaning. For Lucian Leape, it has meant, not just witnessing the historic birth of the health care patient safety movement, but, arguably, creating it.

This book is an invaluable and unique account of the evolution of the evidence, concern, activities, and structures that inform the worlds current understanding of how patients are injured too often by the care that is intended to help them and what can and should be done about that. For a topic of such enormous gravity, involving life-or-death consequences every year for tens of thousands of people in the USA, alone, and many hundreds of thousands globally, this story is remarkably recent. The modern scientific foundations for safety in every sector of human endeavor were laid first no earlier than the mid-twentieth century, and the application of those sciences to medical care, with just a few, slender exceptions, began only in the mid-1980s, barely 40 years ago as of this writing.

It is, of course, not at all the case that medical errors and injuries from care appeared de novo in the past half-century. We know now that hazards to patient safety have been with us as long as there have been patients at all that is, for many millennia. Such hazards come part and parcel with any complex human activity, and even more when that activity includes invading the human body with sharp instruments and foreign chemicals and invading the human psyche with intimidating hierarchies and opaque rites. No count exists of the number of people killed by medical errors since Hippocrates and despite physicians best intentions, but the toll, if known, would be staggering.

The culprits for that toll, we know now, would not be, for the most part, rogue clinicians or even incompetent ones, but rather the very designs of health care delivery, itself, in which even the best of the workforce get trapped. Or, to be clearer, they are the myriad interactions of those delivery system designs and the frailties of unaided human minds and manipulations the so-called human factors that set up normal people most of us for slips, errors, and lapses, the familiar oops of daily life. When I forget to set my alarm clock, thats a nuisance; when I forget to give a medication to a critically ill patient, that can be a disaster. But the causes are the same; being human. Only when medicine ceases to rely on heroism for excellence can the pursuit of real safety begin effectively.

Modern safety sciences and their first cousins, the sciences of human error, first gelled in the 1960s and 1970s. The seeds were there in studies of cognitive psychology, social psychology, and general systems theory of the preceding century or so. But it was not until a group of engineers and psychologists began to name the problems of human error and system safety beginning in the 1960s that the field of safety science coalesced. Among the founders was Professor James Reason, from the University of Manchester, whose 1990 book, Human Error, was and remains the leading monograph on that topic.

Lucian Leape became a student of these emerging sciences of safety not long after Reasons book first appeared. He was primed for the field, having participated as a highly regarded pediatric surgeon in the groundbreaking Harvard Medical Practice Study, which was the brainchild of Dr. Howard Hiatt and New York State Commissioner of Health David Axelrod. That study set out in commanding detail empirical findings about injuries to patients in New York hospitals, defining adverse events, and convincingly showing that the vast majority of those injuries could be seen as preventable, not inevitable.

Streams converged: the evidence of errors and their consequences, the growing awareness of the value of systems thinking regarding health care quality, the maturation of the safety sciences in other industries, and the self-education of Lucian Leape. The result was a turning-point publication: Lucians magisterial December 1994, article in the Journal of the American Medical Association: Error in Medicine. Not often can we trace a change in the consciousness of an entire industry to a single treatise; but this time, we can. Within just a few years of Lucians call to arms, massive shifts were underway in health cares awareness of and concern about patient safety and its defects.

In this book, Lucian recounts the key events and actors preceding and following his seminal article. With dignity and generosity, he describes the contributors to the development of the field he helped to found. Some were conferences, in many of which Lucian had a big role: the Annenberg Conferences where the actual voices of injured patients and families first rang out as loudly as they must; the Salzburg Seminar on Patient Safety, which first brought together a truly international group of patient safety scholars, and which incorporated leading scholars from outside health care, including Jim Reason, himself. Some were action collaboratives, such as IHIs Breakthrough Series Collaborative on Medication Safety, which Lucian, himself, chaired.