What’s New in the Patient Safety World
December
2009
Stories,
Not Statistics
You’ve often heard us use the phrase “Stories, Not Statistics”. When we first began doing presentations on patient safety in the early 1990’s we often began with some of the statistics on medical error from Lucien Leape’s work. But we began to notice physicians and medical students begin to zone out when we talked about statistics on medical error. What they liked were the anecdotes we would tell about cases that really happened. So we changed our focus. While we still often show statistics on medical error to put things in context, we no longer highlight them. Instead, we really rely on the stories. That’s what gets people’s attention. That’s what makes people say “I wonder if that could happen here?” and what makes them go back to look at the systems in their health care systems. It is those stories that hit home hard and make people remember. Who cannot remember their own reactions when they first heard the Josie King story, or the story about the nurse who administered Bicillin intravascularly, or the little boy who died from concentrated epinephrine injection during a simple surgical procedure, or any nurse who inadvertently administered concentrated potassium solutions?
In fact, that is one of the reasons we feel that publication by the Institute of Medicine in 2000 “To Err is Human: Building a Safer Health System” has failed to gain traction despite considerable initial media attention. Everyone focused on the statistics from that report. It lacked the stories about real people you need to tell in order to get people and systems to change.
Others involved in safety in both health care and other industries have clearly valued the role of stories in promoting safety. See our comments on the work of Gary Klein (May 27, 2008 “If You Do RCA’s or Design Healthcare Processes…Read Gary Klein’s Work”) and Eric Hollnagel (September 15, 2009 “ETTO’s: Efficiency-Thoroughness Trade-Offs”).
Now, the National Patient Safety Agency (UK) has come out with exactly that sort of approach we endorse “National Patient Safety Agency: combining stories with statistics to minimise harm”. That is the first of a series of recommendations that will be published in the British Medical Journal to improve patient safety. They describe how reports and stories of incidents will be used to more rapidly call to attention significant patient safety issues. Prior NPSA patient safety alerts often took years of analysis of data before reports were issued. The new approach is a much welcomed one and one that we in the US need to adopt. We have state and national databases replete with lessons learned from patient safety incidents that are sitting there untapped. We don’t need to wait for detailed analysis of statistics to get many of those messages out to our hospitals and health care systems. We tend to wait far too long before we disseminate the valuable warnings and lessons learned. How many instances of inadvertent administration of concentrated potassium chloride did it take before we got the message out that there was a system solution?
References:
Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press, 2000
Lamont T, Scarpello J. Safety Alerts: National Patient Safety Agency: combining stories with statistics to minimise harm. BMJ 2009; 339: b4489
http://www.bmj.com/cgi/content/extract/339/nov19_2/b4489
http://www.patientsafetysolutions.com
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