And we have made progress to reduce errors: we have impressive results in reducing bloodstream infections and surgical checklists have taken off. And we've gotten doctors to quit writing prescriptions on a piece of paper and instead enter them into a computer, which could identify if there were a mistake. The computer remembers what the doctor might forget.
But there's so much to do, they really haven't had the huge impact we'd like. And in the U.S., there's no government direction, support or leadership. It's voluntary…up to whether the doctors and nurses and hospital administration decide to do these things are not. So it's spotty. Some places do it much more than others and have made a real commitment; others are just sort of going along.
HLM: What do we need to do to make healthcare safer?
LL: We need to quit blaming and punishing people when they make mistakes and recognize that errors are symptoms of a system that's not working right, and go figure that out and change the system so no one will make that error again, hopefully. We have to change the culture, so everyone feels safety is his or her responsibility, and identifies hazards before someone gets hurt.
It's the patients, not the doctors, who get hurt
HLM: Why don't doctors and hospitals do this? Is it fear? Or ignorance? Or lack of resources?
LL: That's not a simple answer. Let's put it this way, the consequences of not having safe care are fairly minimal. It's the patients who get hurt, not the hospitals and doctors. There are occasional people who get sued for gross negligence, but that's a tiny fraction, so hospitals can continue to fail to do things we know make a difference because we know there are no consequences (to them).