Martin Makary, in his recent article “Medical error—the third leading cause of death in the US.” He begins with his observations: “The science of safety has matured to describe how communication breakdowns, diagnostic errors, poor judgment, and inadequate skill can directly result in patient harm and death.”
Dr. Makary’s perspectives of human factors in medical errors mirrors the positions of learning from errors and scientific approach of Quture. He observes: “Human error is inevitable. Although we cannot eliminate human error, we can better measure the problem to design safer systems mitigating its frequency, visibility, and consequences.”
Quture advocates the strategy for hospitals to carry out a rapid and efficient independent investigation into deaths to determine the potential contribution of error, the very same words as Dr. Makary. He proposes a root cause analysis approach medico-legal protections to maintain anonymity would enable local earning while using. QualOptima HFCAS introduces a standardized data collection and reporting processes; such a standardized and common database is essential to an accurate national picture of the problem, its causes and solutions.
Optimal outcomes, clinical, operational and financial, depend upon creating a culture of learning from mistakes. The Institute of Medicine’s goal of creating learning health systems depends upon advancing the science of safety. Dr. Makary concludes his article stating: “To achieve more reliable health care systems, the science of improving safety should benefit from sharing data nationally and internationally, in the same way as clinicians share research and innovation about coronary artery disease, melanoma, and influenza. Sound scientific methods, beginning with an assessment of the problem, are critical to approaching any health threat to patients. The problem of medical error should not be exempt from this scientific approach. More appropriate recognition of the role of medical error in patient death could heighten awareness and guide both collaborations and capital investments in research and prevention.”