Abstract
Patient safety is one of those “wicked problems” that has been with us for centuries, but brought to the forefront over a decade ago by a series of reports from the Institute of Medicine. The phrase “wicked problems” refers to problems that are complex and characterized by incomplete and ambiguous understanding of their true nature. The editors of this volume, First, Do Less Harm: Confronting the Inconvenient Problems of Patient Safety, forcefully remind us that the wicked problems of patient safety are not yet solved. The 12 authors, who include health professionals, health researchers, and patients each explore a different facet of the contextual and cultural issues that underlie specific safety concerns. These components include the promise and failure of information technology, how we get hospitals cleaned, fatigue as it affects physicians and nurses, the complex “lives” of front-line caregivers, and the promise and failure of teamwork, among others.
Although the book is a series of authored papers, the writing is clear and even, which reflects good editing from two master writers (Ross Koppel and Suzanne Gordon). A great strength is the multiple perspectives of health care workers, who range from cleaning staff to physicians, nurses, and health care executives. This stands in marked contrast to most books on health care reform that focus on only one profession, usually physicians and sometimes health care administrators. However, even these multidisciplinary papers subtly reflect the silos of health care workers, with little awareness in any essay of their interconnectedness. For example, both nurse and physician fatigue are discussed independently, but there is no explicit intertwining. This is not surprising since the subjects were studied separately, even though many were in the same environment!
The final chapter, “Twenty-Seven Paradoxes, Ironies and Challenges,” attempts a basic or “root cause” analysis of the persistence of these wicked problems. Among the elements of the causes are not involving the unions and front-line workers, and paying lip service to the research about solutions to patient safety problems. However, it seems that even this analysis is aimed at each component of a complex ecologic system, rather than the ecology of the whole. In my view, none of the proposed fixes really look at the ecology of safety—the intertwining of context, culture, and evidence-based management.
Although none was cited in this book, there are a few positive examples in the research literature of substantive positive improvement in safety through consortia that improve the culture of safety at participating hospitals. For example, the Keystone ICU Collaborative in Michigan claims to have reduced serious infection rates through interventions that involved front-line workers and improved the culture of safety (see Hyzy et al. 2012). Other positive examples can be found in a set of systematic reviews published after this book was written (Shekelle et al. 2013). These reviews reinforce the relatively rare consideration of context, culture, and interdependency in patient safety interventions.
The overarching value in the Koppel and Gordon volume is the “in your face” reminder that we are not there yet in terms of patient safety—not anywhere close.