Report from a Workshop on
Assembling the Scientific Basis
for Progress on Patient Safety

At the beginning of the workshop, an analogy was made between the state of health care today and conditions in the nuclear power industry in 1979 after it was staggered by the Three Mile Island accident.

The Three Mile Island accident was a watershed for the nuclear power industry. It irrevocably changed the way people looked at nuclear safety, and this change created both the possibility of and the need for new approaches to safety in that industry.

While there is no single medical event comparable to the Three Mile Island accident, the combined effect of the celebrated medical failures over the last few years is similar. The attention these cases have received, and the debate and action they have engendered, signal a fundamental shift in public perceptions of patient safety. Although the cases are spread out geographically and involve different kinds of failures, in combination they have shifted the public perception of the sources of risk and failure in medicine. The founding of the National Patient Safety Foundation (NPSF) itself is a marker for this change, as are recent initiatives from regulatory, advisory, and legislative bodies.

Health care stands in 1998 where nuclear power stood at the end of 1979. There are growing public demands to enhance patient safety. There is public concern that the financial pressures and organizational change in health care will degrade practitioners' expertise, create conflicting goals and incentives, increase workload, and reduce safety margins. There are concerns about the nature of training and certification of practitioners and institutions. There are anxieties about injuries from a panoply of technological devices, drugs, and techniques. Not everyone is concerned, nor are all in agreement about the sources of hazard or the appropriate responses. There is confusion and argument about the meanings of events. In this, there is a close parallel to the time just after the Three Mile Island accident.

This situation is fraught with promise and also with risk, hence, "it is the best of times, and the worst of times" to explore safety in health care.

Despite the fact that celebrated and uncelebrated cases underscore medicine's fallibility, health care today is more technically advanced than it has been at any other moment in history. But the ever advancing state-of-the-art of medicine has been coupled with ever increasing complexity. Against a backdrop of organizational change and economic pressures, the increasing complexity of health care increases the possibilities for unanticipated and unintended consequences. As a result, even more opportunities for failure may exist.

The intense interest generated by medical accidents may provide opportunities to advance patient safety. Political will and economic investment follow public attention and can provide the energy to implement meaningful change in health care. On the other hand, there is a downside to this sort of public attention. The need to do something, to react quickly, to provide visible (if not substantive) evidence of progress, may result in a rush to implement unproductive or counterproductive programs. It may even result in direct efforts to manipulate the image of safety to promote political or economic interests.

Defining Opportunities and Obstacles

In this context, we asked the gathered experts on safety related issues to help us take the existing research base as a guide for how we could move forward on safety in health care.

To this end we posed a series of safety-related questions to the participants:

• What lessons can we learn from studies of failure and success in other domains?
• What scientific knowledge is available regarding the human contribution to risk and safety?
• Given the scope and complexity of health care, the diverse collection of issues that influence individual health care practitioners and coordination across health care teams, technological factors, organizational context, and regulatory pressures-What are the opportunities and obstacles for making progress on patient safety?
• What can the research base teach different stakeholders in health care about the factors that produce failure?
• What can the research base tell us about the kinds of investments and changes that will enhance safety?
• What cautions or warnings about unproductive or counterproductive approaches are needed?
• What meaningful guidance can we provide about the priorities for future research and applications?