Developing a patient safety culture: What can we learn from other industries?

May 17, 2019 / By Priscilla Knolle, MD

The publication of the Institute of Medicine report To Err Is Human: Building Safer Health System in 1999 raised awareness of medical errors, increased public concern and called for a national effort to improve healthcare safety. The report concluded that 44,000 to 98,000 people die each year as a result of preventable medical errors.[1] The IOM report led The Joint Commission to establish its National Patient Safety Goals (NPSGs) program in 2002 to “help accredited organizations address specific areas of concern in regard to patient safety.” [2]

More recently, a new report on medical errors, published in 2016 by one of the world’s oldest general medical journals, The BMJ, shared disturbing and discouraging news. Titled “Medical errors- third leading cause of death in the U.S,” [3] the article’s researchers Martin Makary and Michael Daniel at Johns Hopkins University School of Medicine stated that while “accurate data on deaths associated with medical error is lacking, recent estimates suggest a range of 210,000 to 400,000 deaths a year among hospital patients in the U.S.” (The BMJ Press Release, May 4, 2016). Safety is a much-needed cornerstone of healthcare delivery and a culture of safety is essential to preventing and/or reducing errors. Additionally, a safety culture promotes improved clinical and quality outcomes for patients.

The concept of a safety culture originated outside health care, most notably in the aviation and oil and gas industries, which have achieved exemplary records over time. The cultures of these industries demonstrate common elements or themes, such as leadership commitment to safety, employee engagement, lack of a “blame” culture and continuous improvement. Efforts to promote a safety culture within the oil and gas industry, for example, can be traced to the 1989 Exxon Valdez oil spill in Alaska. Considered one of the worst environmental disasters ever, spilling 10.8 million U.S. gallons of oil into the ocean, resulting in the death of hundreds of thousands of seabirds, otters and other marine life and impacting commercial fishing, tourism and the lives of people.

With this history in mind, I discussed the safety journey with Anil Mathur, CEO and President of Alaska Tanker Company (ATC). ATC, a Ship Management and Marine Transportation company, has carried 60 billion barrels of crude oil to date. During Mathur’s seventeen-year tenure as CEO, ATC has had no spills at sea. In addition to this environmental safety record, there have been no employee injuries, except one finger fracture, in 23 million hours of work which is astounding given the high demand physical nature of this industry. Reputed as the “CEO who gets it” by the National Safety Council in 2005, Mathur also serves on the Board of the American Society of Safety Professionals, receiving their President’s Award for his contribution to safety.

In the weeks ahead, I will share my conversation with Anil Mathur with the goal of discovering lessons from ATC’s safety journey within the oil industry, which can both inspire and inform healthcare safety culture. I hope you will join me in this journey.; Please feel free to share your insights, experiences and ideas on this blog. You can also reach me at pknolle@mmm.com.

Priscilla Knolle, MD, CPHQ, CHDA, CCS, is a Clinical Transformation Consultant at 3M Health Information Services.

[1] Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Editors, To Err Is Human: Building Safer Health. (Washington, D.C.: NATIONAL ACADEMY PRESS, 2000), 2, https://www.nap.edu/read/9728/chapter/1

[2]  “Facts about the National Patient Safety Goals,” The Joint Commission, accessed May 7, 2019, https://www.jointcommission.org/facts_about_the_national_patient_safety_goals/

[3] Martin A. Makary and Michael Daniel, “Medical error—the third leading cause of death in the US,” BMJ 2016; 353 :i2139, https://doi.org/10.1136/bmj.i2139