In 2009 a team of knowledgeable experts including Don Berwick and Lucian Leap came together to define patient safety. In a published paper they articulated a definition, description and model of patient safety. Their definition, loosely paraphrased was a “discipline in the health care professions that applies safety science toward the goal of achieving a trusted system of healthcare delivery; a system that minimizes incidence of adverse events, reduces error and maximizes recovery from such events if they occur”. They further stated that the field of patient safety existed because of the high incidence of avoidable adverse events and the need for the use of safety science and methods for causing change to include cultural change.

Patient Safety

Many changes to improve patient safety have taken place since that paper was written; an emphasis on team training, the use of checklist, a cultural change in respect an equality of all healthcare givers, the development of well defined reporting and data systems, etc. However, as many changes as have taken place we continue to have daily adverse events and hospitals are simply not safe places to be.

Peter Pronovost, at the Subcommittee, Patient Safety Hearing held on July 17, 2014 said “Medicine today squanders a third of every dollar spent on therapies that do not get patients well, that result from treating preventable complications, and that result from administrative inefficiencies and fraud. This is about $9000 per US household that could be better spent on preschool education and STEM, on innovation, and on securing a better tomorrow.” He further stated that the consensus among economists is that improvements come largely through improved productivity from innovation, with improvements in one sector spilling over into others.

We have seen many changes in curriculum design in medical schools, in hospitals in simulation centers and throughout the medical establishment. Some of the schools and simulation centers we have visited have amazing curricula that has been developed to educate and train health care givers. This education and training shows tremendous advancement in the learners’ ability and knowledge and could be shared with other schools, simulation centers and hospitals. This is not happening. In countless encounters we have been shown new materials, tools and training methods that are ‘state of the art’ but not shared. Why? These are not shared because of intellectual property law; more specifically the thinking that views safety improvements as IP.

According to the US Constitution, art. 1 sec 8. cl.8, the stated objective of most intellectual property law (IP) (with the exception of trademarks) is to ‘promote progress’. Another definition of Intellectual Property (Wikipedia) is a term referring to creations of the intellect for which a monopoly is assigned to designated owners by law. Unfortunately and to the detriment of progress the second definition is the one most universities, simulation centers, hospitals and other bodies of learning adhere.

Yes, money is made from IP, and all these institutions run on money. Notwithstanding, it is difficult to see a great curriculum or training tool that has been developed and know it will only be used by that entity. It is difficult to watch the ‘re-invention’ of the wheel over and over.

Several years ago the AAMC made a valiant effort to reduce IP in medical schools but were thwarted at almost every turn. We applaud their effort and would like to see other entities do the same.

Can the healthcare sector really afford the current duplication of effort that this mindset breeds, further hampered by the ‘academic’ approach that encourages everyone to produce ‘original research’, actually delaying improvement, rather than simply taking ‘best practice’ and continually improving it.

An entity, or entities, need to identify these best practices, select one that most can accept, if not endorse, and establish it as the standard that its community works to and punish those that do not. As a better version emerges the process should continue as should the process to a safety driven business. If the mechanisms to do so do not exist then create them! The sector knows how to do this and it should.