Still Not Safe

by Robert L. Wears & Kathleen M. Sutcliffe

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Publisher: Oxford University Press
Copyright: November 2019
ISBN: 0-19-027128-0
Format: Kindle
Pages: 232

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Still Not Safe is an examination of the recent politics and history of patient safety in medicine. Its conclusions are summarized by the opening paragraph of the preface:

The American moral and social philosopher Eric Hoffer reportedly said that every great cause begins as a movement, becomes a business, and eventually degenerates into a racket. The reform movement to make healthcare safer is clearly a great cause, but patient safety efforts are increasingly following Hoffer's path.

Robert Wears was Professor of Emergency Medicine at the University of Florida specializing in patient safety. Kathleen Sutcliffe is Professor of Medicine and Business at Johns Hopkins. This book is based on research funded by a grant from the Robert Wood Johnson Foundation, for which both Wears and Sutcliffe were primary investigators. (Wears died in 2017, but the acknowledgments imply that at least early drafts of the book existed by that point and it was indeed co-written.)

The anchor of the story of patient safety in Still Not Safe is the 1999 report from the Institute of Medicine entitled To Err is Human, to which the authors attribute an explosion of public scrutiny of medical safety. The headline conclusion of that report, which led nightly news programs after its release, was that 44,000 to 120,000 people died each year in the United States due to medical error. This report prompted government legislation, funding for new safety initiatives, a flurry of follow-on reports, and significant public awareness of medical harm. What it did not produce, in the authors' view, is significant improvements in patient safety.

The central topic of this book is an analysis of why patient safety efforts have had so little measurable effect. The authors attribute this to three primary causes: an unwillingness to involve safety experts from outside medicine or absorb safety lessons from other disciplines, an obsession with human error that led to profound misunderstandings of the nature of safety, and the misuse of safety concerns as a means to centralize control of medical practice in the hands of physician-administrators. (The term used by the authors is "managerial, scientific-bureaucratic medicine," which is technically accurate but rather awkward.)

Biggest complaint first: This book desperately needed examples, case studies, or something to make these ideas concrete. There are essentially none in 230 pages apart from passing mentions of famous cases of medical error that added to public pressure, and a tantalizing but maddeningly nonspecific discussion of the atypically successful effort to radically improve the safety of anesthesia. Apparently anesthesiologists involved safety experts from outside medicine, avoided a focus on human error, turned safety into an engineering problem, and made concrete improvements that had a hugely positive impact on the number of adverse events for patients. Sounds fascinating! Alas, I'm just as much in the dark about what those improvements were as I was when I started reading this book. Apart from a vague mention of some unspecified improvements to anesthesia machines, there are no concrete descriptions whatsoever.

I understand that the authors were probably leery of giving too many specific examples of successful safety initiatives since one of their core points is that safety is a mindset and philosophy rather than a replicable set of actions, and copying the actions of another field without understanding their underlying motivations or context within a larger system is doomed to failure. But you have to give the reader something, or the book starts feeling like a flurry of abstract assertions. Much is made here of the drawbacks of a focus on human error, and the superiority of the safety analysis done in other fields that have moved beyond error-centric analysis (and in some cases have largely discarded the word "error" as inherently unhelpful and ambiguous). That leads naturally to showing an analysis of an adverse incident through an error lens and then through a more nuanced safety lens, making the differences concrete for the reader. It was maddening to me that the authors never did this.

This book was recommended to me as part of a discussion about safety and reliability in tech and the need to learn from safety practices in other fields. In that context, I didn't find it useful, although surprisingly that's because the thinking in medicine (at least as presented by these authors) seems behind the current thinking in distributed systems. The idea that human error is not a useful model for approaching reliability is standard in large tech companies, nearly all of which use blameless postmortems for exactly that reason. Tech, similar to medicine, does have a tendency to be insular and not look outside the field for good ideas, but the approach to large-scale reliability in tech seems to have avoided the other traps discussed here. (Security is another matter, but security is also adversarial, which creates different problems that I suspect require different tools.)

What I did find fascinating in this book, although not directly applicable to my own work, is the way in which a focus on human error becomes a justification for bureaucratic control and therefore a concentration of power in a managerial layer. If the assumption is that medical harm is primarily caused by humans making avoidable mistakes, and therefore the solution is to prevent humans from making mistakes through better training, discipline, or process, this creates organizations that are divided into those who make the rules and those who follow the rules. The long-term result is a practice of medicine in which a small number of experts decide the correct treatment for a given problem, and then all other practitioners are expected to precisely follow that treatment plan to avoid "errors." (The best distributed systems approaches may avoid this problem, but this failure mode seems nearly universal in technical support organizations.)

I was startled by how accurate that portrayal of medicine felt. My assumption prior to reading this book was that the modern experience of medicine as an assembly line with patients as widgets was caused by the pressure for higher "productivity" and thus shorter visit times, combined with (in the US) the distorting effects of our broken medical insurance system. After reading this book, I've added a misguided way of thinking about medical error and risk avoidance to that analysis.

One of the authors' points (which, as usual, I wish they'd made more concrete with a case study) is that the same thought process that lets a doctor make a correct diagnosis and find a working treatment is the thought process that may lead to an incorrect diagnosis or treatment. There is not a separable state of "mental error" that can be eliminated. Decision-making processes are more complicated and more integrated than that. If you try to prevent "errors" by eliminating flexibility, you also eliminate vital tools for successfully treating patients.

The authors are careful to point out that the prior state of medicine in which each doctor was a force to themselves and there was no role for patient safety as a discipline was also bad for safety. Reverting to the state of medicine before the advent of the scientific-bureaucratic error-avoiding culture is also not a solution. But, rather at odds with other popular books about medicine, the authors are highly critical of safety changes focused on human error prevention, such as mandatory checklists. In their view, this is exactly the sort of attempt to blindly copy the machinery of safety in another field (in this case, air travel) without understanding the underlying purpose and system of which it's a part. I am not qualified to judge the sharp dispute over whether there is solid clinical evidence that checklists are helpful (these authors claim there is not; I know other books make different claims, and I suspect it may depend heavily on how the checklist is used). But I found the authors' argument that one has to design systems holistically for safety, not try to patch in safety later by turning certain tasks into rote processes and humans into machines, to be persuasive.

I'm not willing to recommend this book given how devoid it is of concrete examples. I was able to fill in some of that because of prior experience with the literature on site reliability engineering, but a reader who wasn't previously familiar with discussions of safety or reliability may find much of this book too abstract to be comprehensible. But I'm not sorry I read it. I hadn't previously thought about the power dynamics of a focus on error, and I think that will be a valuable observation to keep in mind.

Rating: 6 out of 10

Reviewed: 2022-08-13

Last modified and spun 2022-08-14