Patient Safety Past , Present , and Future

Patient safety is not a new issue. Some think it was born with the Institute of Medicine’s report “To Err is Human: Building a Safer Health System,” but it has been discussed in one form or another for years. It has been an issue throughout the history of medicine, but it has never been publicized to the extent that it has during the past 5 years. For example, in 1847, Dr. Semmelweis first noted that postpartum fever and death, which was present in approximately 20% of women giving birth, could be reduced to approximately 1% if physicians and midwives washed their hands. But no one listened to him. Physicians were very skeptical; therefore, he was not able to alter their practice. No one changed his or her habits and the postpartum fever death rate remained at 20%. Semmelweiss’ life, however, changed dramatically; he was denied promotion at the University and essentially was fired from his hospital. He tried to obtain staff privileges at other hospitals without success. Finally, at age 47, he died in an insane asylum. Today, just as Semmelweis had advocated 150 years ago, hand washing is being emphasized in each hospital and with each patient contact. It has reached a level of importance that, in some hospitals, individuals are assigned to observe physicians’ and nurses’ behavior when entering a patient’s room to ensure that they wash their hands before examining the patient. Hospitals are developing educational programs on the benefits of hand washing to decrease nosocomial infections. Patients also are beginning to demand that physicians and nurses wash their hands before examination. Isn’t it remarkable that the patient, the public, and hospitals have to ask physicians and nurses to do what is right, to wash their hands before examining the patient? In 1917, almost 90 years ago, Codman stressed the importance of measuring and reporting patient outcomes by hospitals and surgeons. He insisted that they be made public so everyone would know hospitals’ and surgeons’ outcomes. Dr. Codman, like Dr. Semmelweis, was not respected by his colleagues for his visionary opinions and essentially was ignored. He finally left the Massachusetts General Hospital, where he practiced, and built his own hospital so he could report patient outcomes. Today, we still are discussing outcomes of care, discussing how to analyze, how to report, what to report, who to report to, and who should be reporting, without significant movement. Although the public is increasingly asking about results of care and medical errors, the medical profession has remained essentially silent. Another early publication on patient safety in 1964 indicated that iatrogenic injury occurred in 20% of hospitalized patients. In the early 1970s the American College of Surgeons and the American Surgical Association found that 1⁄2 of nonfatal complications and approximately 1/3 of deaths from surgery were preventable. Also in the 1970s, From the Department of Orthopaedics, Harvard Medical School, Boston, MA. Earl McBride Lecture presented at the Association of Bone and Joint Surgeons Annual Meeting, Nashville TN, June 17, 2004. Correspondence to: James H. Herndon, MD, Department of Orthopaedics, Harvard Medical School, 55 Fruit St – GRB 624, Boston, MA 01970. Phone: 617-726-5117; Fax: 617-726-3124; E-mail: jherndon@partners.org. DOI: 10.1097/01.blo. 0000163837.66906. 3d CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Number 440, pp. 242–250 © 2005 Lippincott Williams & Wilkins