Dr. Brian Goldman On Patient Safety

Mediaplanet: Do you think that an issue such as lung health - one that is under-funded and under-represented in the health care industry - has repercussions in the realm of patient safety? How are these manifested?

Dr. Brian Goldman: In general, lung health is underfunded in Canada.  There are many indications of this. Chronic obstructive pulmonary disease (COPD) receives far less attention than heart disease and stroke. Patient advocacy groups have given lots of attention to breast cancer, and (to a lesser extent) prostate cancer.  By comparison, lung cancer receives far less attention.  Much of this may be attributed to the widespread belief among Canadians that COPD and lung cancer are “self-inflicted” diseases because they are caused by smoking.  With rising rates of lung cancer among Canadians who have never smoked, this perception may one day change.

MP: What is the most important issue one must address when dealing with patient safety and why? 

BG: To me, when it comes to patient safety, the most important issue we must address is to develop within health professionals the ability and the desire to be curious about the mistakes they make. In my opinion, doctors and other health professionals tend to experience unhealthy shame about the mistakes they make.  With healthy shame, the focus is on the mistake you made; with unhealthy shame, you tend to focus on flaws in your character. Healthy shame motivates one to improve and to make restitution. Unhealthy shame leads one to seek ways of escaping the bad feelings that accompany it.  These include rationalization, blaming others, seeking distraction, and even drinking alcohol and taking other mood altering substances.

"In general, lung health is underfunded in Canada.  There are many indications of this. Chronic obstructive pulmonary disease receives far less attention than heart disease and stroke."

When one is ashamed of one’s mistakes, one does not want to review them and learn from them. It is nearly impossible to be curious about mistakes if one is ashamed of them. With no curiosity, there is no motivation to learn from mistakes, to find solutions, and to teach others those solutions.  As a result, our health care system is not as safe as it could be; many more patients suffer preventable harm and death that could be prevented if doctors and other health care providers developed curiosity about their errors.

One doctor who “gets ”what I mean is Dr. Teodor Grantcherov, a surgeon at St. Michael’s Hospital in Toronto.  Grantcherov has long been curious about mistakes made by surgeons in the operating room, beginning with his own. Since his residency in general surgery, Grantcherov has been recording his technique in the operating room, and has used those recordings to make fewer errors. Now, he is using that technique to determined what kinds of errors surgeons make and how to reduce them.

MP: What are the notable progressions being made by the health care industry to improve patient safety? 

BG: The most important improvement I see in health care is that we are talking about medical errors and patient safety. This is something that was spoken of in hushed whispers as little as twenty years ago. Doctors and other health care professionals are talking about their mistakes, and are encouraging others to do the same.  When a lecture of mine was posted to TED.com, I had no idea what kind of response I was going to receive.  Nearly two years later, my TEDtalk has been viewed close to 900,000 times, and I have received all kinds of warm wishes from fellow health professionals and patients alike.

"The most important improvement I see in health care is that we are talking about medical errors and patient safety. Doctors and other health care professionals are talking about their mistakes, and are encouraging others to do the same."

I have seen technology begin to be used to improve patient safety.  Bar-coded patient labels are being used to make certain the right patient receives the right medication and the right blood donation. In pharmacies, software is being developed and implemented to reconcile complex lists of medications so that at each step along the journey through the health care system, the patient has the correct and up-to-date list of medications. 

Hospitals are hiring patient safety officers, where none existed before. When an error is made, hospitals are trying to be much more transparent about the mistake and what they plan to do about it.  As a society, when a series of major errors takes place, I am confident that we hear about as soon as it is discovered.  This was certainly not true a generation ago. 

The future looks intriguing as well.  Dr. Teodor Grantcherov is developing the prototype of a black box that can store and reproduce information gathered during an operation. Patterned after the flight data recorder used in aviation, I believe that the operating room black box will one day be an essential tool to help doctors and hospitals understand how and why medical errors take place and how to prevent them.

MP: How can Canadians be empowered in the promotion of safe health care? How does educating Canadians on lung health promote safety within health-care?  

BG: Canadians play an important role in promoting safe health care. The first thing they need to do is to say out loud that while acknowledging that health professionals are human, they nevertheless want and demand the safest health care possible. The other thing Canadians can and should do is become the most well-informed and engaged patients possible. That means knowing what diagnoses they have, what medications they take, and by asking their health professionals lots of questions. 

"Educating Canadians on the importance of handwashing – and encouraging engaged patients to ask health professionals if they wash their hands – can reduce this important source of preventable harm."

A few forward-thinking hospitals have embraced patient engagement as a powerful tool to make patients safer in hospitals.  Kingston General Hospital has recruited former patients and family members of former patients as advisors.  These volunteers sit on numerous hospital committees and advise hospital staff on everything from what signs to post to which nurses and other health professionals to hire.  Their efforts have boosted hand-washing rates among health professionals to 95% from the previous rate of just 35%.

One particular example has to do with educating Canadians on lung health.  Poor handwashing rates among health professionals leads to higher rates of hospital-acquired lung infections among hospitalized patients.  Educating Canadians on the importance of handwashing – and encouraging engaged patients to ask health professionals if they wash their hands – can reduce this important source of preventable harm.

MP: What are the misconceptions surrounding patient safety?  What are the misconceptions surround lung health? Why do these misconceptions arise and how do we best counteract them?

BG: The most important misconception surrounding patient safety is that health professionals never make mistakes.  Being human, health professionals make mistakes each and every day.  A related misconception is that health professionals are never supposed to make mistakes.  I like to bring up the example of the batting average, a statistic used in baseball.  A batting average is the number of times a batter hits safely as a percentage of the total number of at-bats.  An excellent ball player finishes the season with a batting average of .300, which means the batter hit safely and reached based without being thrown out thirty times out of every one hundred bats – a thirty percent success rate. 

"Once we have a new more realistic mindset in place, a system can be developed to monitor health professionals for inevitable errors, to develop ways to identify them quickly and to mitigate the damage caused by them."

If your doctor were to tell you she has a 30% success rate at treating pneumonia, you would be horrified!  But what should a doctor’s success rate be?  As a veteran physician, I can tell you that no such statistics exist.  The implicit assumption is that doctors should have a 100% success rate, which I maintain is impossible to achieve. 

This misconception has held for so long because doctors and the system have helped to maintain it.  Doing so preserves the place doctors occupy in the hierarchy of health care.  Patients and society love the misconception because it absolves them of the responsibility to pay more attention to what doctors are doing.

The best way to counteract assumptions like these is to declare that we expect health professionals to try their best and yet we also expect that we will make mistakes.  Once we have a new more realistic mindset in place, a system can be developed to monitor health professionals for inevitable errors, to develop ways to identify them quickly and to mitigate the damage caused by them.