Making a career in patient safety: How I got hooked

When I was beginning my academic career, there was no field of study entitled “patient safety.” After medical school and training in internal medicine, I decided to apply to the Robert Wood Johnson Clinical Scholars Program for a research fellowship. Their objective was to provide nonbiological training to physicians to increase access to health services, improve quality of care, and generate evidence to support health care policy. ¹ The application required a proposal for research to be completed during the two-year fellowship. At first, I was stymied. I was unsure of what research topic I was most interested in.

After days of pondering over potential questions, I fixed on the issue of medical mistakes. This may have been inspired by my own experiences with errors that had involved me and my colleagues during training. There was little to be found on the topic in the published literature. I wrote in the application:

Medical error is not the exclusive purview of incompetent and impaired physicians, but is inevitable and involves all practitioners… physicians often fail to inform their patients, colleagues or supervisors that they may have caused an illness or complication… This underreporting of medical mistakes has far-reaching consequences for the quality of care and doctor–patient relationships.

I proposed to survey physicians on their willingness to discuss their mistakes with peers, and to incorporate into hospital and ambulatory care a “tested procedure for the reporting and analysis of error.”

At the time, the relevant keyword was still “medical error,” as the term “patient safety” had not been invented. There were no targeted training programs on the subject. During my interviews for the fellowship, I encountered both support and skepticism. One eminent professor told me that “the idea was interesting, but certainly no one would ever make a career out of it.” I was fortunate to be accepted and spent the next two years doing research supervised by Professors Bernard Lo, Steve McPhee, and Susan Folkman at UC San Francisco. The study we completed was the first to investigate the experience of medical residents with errors and was covered widely by the media. ²

I was hooked. I took a faculty position at Johns Hopkins and worked for the next decade on the handling and impact of patient safety incidents.^3,4 Since the release of the National Academy of Medicine's 1999 report To Err is Human and the start of the World Health Organization's World Alliance for Patient Safety, patient safety has been the major focus of my research.^5,6

How were other top leaders in patient safety first attracted to the field? Were they motivated by personal or clinical experiences? Was there an observation that provoked them to search for an answer?

In this editorial, we provide narratives from members of our international editorial board on how they got hooked on patient safety. Some were motivated by an adverse event. Others were captured by a compelling question. For still others, the mechanism was simply the search for a job or being ordered to take on a project.

Professor Charles Vincent was one of the first to conduct research on the causes of harm to patients and methods of improving healthcare safety. He has served in many influential roles in academia and government in the UK and as an advisor worldwide. He is currently an Emeritus Fellow of Jesus College and Professor of Psychology at Oxford. He writes,

I first became involved because I needed a job in the psychology department where I was doing a PhD. A post was advertised for a project on “Avoidable mishaps in medicine” with Professor Bob Audley, and I took up the post in 1985.

He adds, “Why I then continued such a strange line of work is a longer story.”

Professor Anupam Sibal, who is a Group Medical Director for the Apollo Hospitals Group in India, was first attracted to the field when the founding Chairman of his hospital group asked the question “Do we provide safe care?” He writes, “That question started the journey.” The team began with identifying existing accreditation systems and zeroed in on the Joint Commission International, which led to their first accreditation of a hospital in India. This further led to developing a clinically balanced scorecard to measure outcomes, the creation of the Apollo Quality Program and Apollo Standard of Clinical Care, and an International Patient Safety Congress. “One project led to another exciting project till patient safety and risk management became a part of the work DNA.”

Professor Shin Ushiro is Director of Patient Safety, Kyushu University Hospital (KUH), and a national leader and advisor on quality health care in Japan. He writes, “There were many unprecedented events in my career and interest in patient safety.” He was originally a surgeon, but around 2000 he was at the Ministry of Health in Tokyo on human resource exchange program. This experience led him “to obtain a wider view on healthcare issues, including the emergence of concerns in society about patient safety.” He continues,

I came back to KUH in 2003 to continue my career as a surgeon. But the Ministry of Health (MoH) and Japan Council for Quality Health Care (JQ) called on me to come back to Tokyo to commence and run the national incident reporting and learning system. At the time, I had no option but to take the position, while thinking that the system wouldn’t be successful because no institution wants to report adverse events during times that media and citizens are inclined to blame medical professionals. Contrary to the prediction, the number of reports increased. What was worse (or better) was that the leading political party, the MoH and the JQ planned to launch a no-fault system for birth injury which since 2009 has also succeeded in improving safety and mitigating lawsuits. In addition, in 2014 the need arose at KUH to deploy a chief patient safety officer. Again, I had no option but to take this position. Since then, I’ve been in charge of the JQ project, as well as serving as Professor and patient safety lead.

Ezequiel Garciá Elorrio is a general internist and professor of public health at Centro de Educación Medica e Investigaciones Clínica (CEMIC) in Argentina, founder and board member of the Institute for Clinical Effectiveness and Health Policy, and head of the Department of Health Quality and Patient Safety. He is the current President of the International Society for Quality in Healthcare. He writes,

As a clinician my motivation to work in patient safety was related to witnessing and being part of the tragedy of preventable deaths and adverse events. These have dramatic effects on patients, families and providers such as myself. I wanted to contribute to the solution through research, education, implementation, and advocacy.

Professor Pa-Chun Wang is an otolaryngologist at Fu Jen Catholic University School of Medicine in Taipei, and immediate past Chief Executive Officer of the Joint Commission of Taiwan (JCT). His research has focused on outcomes research, healthcare quality, and patient safety. He wrote,

I was trained in the Harvard School of Public Health back in the mid 1990s, and was especially interested in quality in healthcare. After graduation I continued to do clinical outcomes research at Mass Eye and Ear Infirmary and then Taiwan. When patient safety emerged in the early 2000s, I had the chance to establish and lead the quality management center in my hospital. I started my work with JCT in 2004, helped to establish and operate the Taiwan Patient Safety Reporting system, and was appointed CEO 2017. In that capacity I was in charge of Taiwan's nationwide patient safety work.

All of the papers that appear in this issue of the Journal point to opportunities for careers in patient safety.

Dissanyake et al. ⁷ conducted a systematic review of challenges to integrating patient safety into nursing curricula in Sri Lanka. They identified needs including a theory–practice gap and curriculum development that would require nurse educators with expertise in patient safety.

Goncharuk et al. ⁸ studied the problem of second victims in Croatia. They expressed the need for active medical workers trained in supporting clinicians after adverse events.

Woodier et al. ⁹ discuss the unrealized opportunity to learn from patient safety near misses (PSNMs, also referred to as close calls). Interviews conducted across different healthcare contexts in the British National Health Service suggest that little progress has been made. The authors assert the need for improved efforts to investigate PSNMs.

Yilmaz et al. ¹⁰ reported on the patient safety competency of nursing students in Turkey. Based on their results, they call for inclusion of compulsory patient safety education in the nursing curriculum.

Smith et al. ¹¹ reviewed cases of wrong-site skin surgery in the UK and suggested a five-step approach to prevent this problem. They did not explicitly mention the need for patient safety experts in dermatology. However, a review of the literature reveals very few dermatologist experts in patient safety and related publications.

In the last three decades, patient safety has grown into a new field of research and practice. There is an increasing number of opportunities to work in research, practice, and policy in patient safety. Research in patient safety has gained respect, and many future researchers and practitioners enter the field through training in other established clinical professions. Others do so through additional channels, as offerings in training and education have proliferated. ¹² Universal undergraduate education for health professionals is now a topic of discussion. ¹³

Patient safety has entered the mainstream of clinical sciences. However, there is still a great need for research, operations, and policy to improve healthcare safety. Professionals today have many options to make a career in the field. A quote attributed to Aristotle captures the opportunity, “At the intersection where your gifts, talents, and abilities meet a human need; therein you will discover your purpose.”