And the Headline Reads…

In the last few months I have been paying particularly close attention to the headlines on the dire state of patient safety in the United States.  Here are just a few that remind us all how much work there is to do in healthcare.

How is it that in the best country in the world where we spend the most on healthcare of any country in the world that it is so dangerous to be a patient in a hospital?  Well, if the problems were easy I guess the I wouldn’t be writing about it.  That is what I thought when I started my research.  But guess what, the problems are easy.

From the first story above, Measures to prevent infection are simple and include careful handwashing, hygiene and screening patients when they check in. However, these measures are difficult to enforce, many studies have found.

From the second story, A Massachusetts General Hospital patient died last month after the alarm on a heart monitor was inadvertently left off, delaying the response of nurses and doctors to the patient’s medical crisis.

And from the third story, Root cause analysis revealed that a therapist had programmed “wedge out” rather than “wedge in” on the machine. Another therapist failed to catch the error. On 27 occasions, during treatment, the computer screen clearly read “wedge out.” 27 times! And no one noticed that on the computer screen during treatment.

Why is it that we cannot solve these simple problems 100% of the time?  It is not that we don’t have the technology as the second and third story indicate.  It is not that healthcare entities do not understand that they need to implement good process, policies and procedures. If you have a friend or relative in healthcare, they can bend your ear for hours on the amount of training or communication they receive on a new process or system.  And while we are discussing those that work in healthcare, it is not that healthcare workers do not care enough about the outcomes of their patients, as you can not get into healthcare unless you really care about helping people.

The reality is that healthcare is simply more complex that any other business that I know anything about.  A single Emergency Room on a single day may be presented with heart attacks, gun shot wounds, burn victims, motor vehicle accident victims, stroke victims, “fakers and frequent fliers”, broken bones, etc.   The technologies, processes, and protocols deployed in each of the cases listed varies widely, yet each protocol requires significant mastery of the technology and understanding of the protocol and process.

So the bad news is patients are not as safe as they could be.  The good news is there is plenty of opportunity for someone like you to make it better everyday.   Are you incorporating patient safety into every healthcare IT project in which you are involved?   Are you asking yourself how you can improve patient safety with each project that your are involved?  I hope so.

Please leave a comment telling how you incorporate patient safety into your healthcare IT job.

About the author


Joe Lavelle

Joe Lavelle is the Co-Founder of intrepidNow. Prior to that Joe was an accomplished healthcare IT executive and career coach with a record of successfully meeting the business and technology challenges of diverse organizations including health plans, health delivery networks, health care companies, and several Fortune 500 companies.

Joe is also the author of Act As If It Were Impossible To Fail, available on Amazon.


  • Joe,
    Since the first IOM report and my recognition that IT could both positively and negatively impact healthcare I have incorporated safety into every project in the following way: Consider the “high risk areas” as those that have Core measures or Patient Safety goals as stated by JCAHO or NQF. Do future state design for clinical systems such that these items receive special attention and consideration. Be sure that the clinicians in an organization are engaged in the process and have input to the decisions that are made. Remember that not all the safety risks have been identified yet and be thoughtful in the deliberations that create a new IT environment for the clinicians and most importantly of all … THE PATIENTS …

  • I’m not sure it will ever be possible to identify all risks, nor do I think policy or technology will 100% solve the ones we do. People are fallable and enforcement and compliance of the solutions for the risks that are identified will never be 100% as long as people are involved.

    With that said, I too am amazed that we still have many of the issue that we do today. Increased attention should be paid in every IT project to patient safety and preventing preventable incidents. Real progress will be made when Patient Saftey goes from awareness to a value engrained in the culture of the IT organization. Although we have had much discussion, press, and focus on Patient Saftey over the last decade, there is obviously a long way to go.

  • Dan and Karen – thanks so much for your thoughtful comments. If we all incorporate safety into our projects, we will make a meaningful difference! Best wishes -Joe

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