The Four Greatest Weaknesses in the American Healthcare System Fueling Preventable Harm
By ECRI President and CEO, Dr. Marcus Schabacker, MD, PhD
Every clinician swore an oath to “do no harm,” and yet, while unintentional, preventable harm is inflicted on patients every day in healthcare.
For decades, valiant efforts have been underway to improve patient and workforce safety. Some healthcare providers have made significant progress – several of which came to the forefront a few weeks ago when ECRI joined healthcare leaders from across the U.S. to lead a dialogue at the White House Healthcare Safety Forum. ECRI was honored to moderate a panel that showcased some of the proven interventions and principles that are foundational to highly successful safety efforts. These successes offer valuable lessons that can be scaled to have a broader impact across the healthcare industry.
Despite ongoing efforts, the hard truth remains: we have yet to make meaningful progress in advancing healthcare safety on a national scale. Decades after the watershed To Err Is Human report published in 1999, we still see alarming rates of preventable harm. Adverse events were identified in nearly one in four patient admissions, and approximately a quarter of the adverse events were preventable, when researchers revisited the 1999 study last year.¹
Nearly all the safety hazards in healthcare today can be addressed by eliminating these four widespread weaknesses that fuel preventable harm in the delivery of care:
#1: Neglecting systems-based solutions
The adage remains true: Every system is perfectly designed to get the results it gets. That means, if we consistently get bad results in healthcare, our systems are wrong – not the people in it. When a patient experiences an adverse event, it is most likely the result of a system failure. We must stop blaming harm on a single point, process or person.
For far too long, the healthcare industry has tried to address medical errors by attempting to isolate harm causes in silos. We simply will not make sustainable safety improvements without a systems-approach and radical transparency. Other high-risk industries like the military, aviation and nuclear power already embrace systems-thinking, but it is not consistently implemented across healthcare, yet.
Too many industry leaders approach healthcare as a purely social system – but you cannot ensure safe care through training and workforce education alone. Healthcare is a complex socio-technical system where the physical environment, tasks and processes, tools and technology, the overarching organization, its people, the patients and their caregivers, and the external environment are inextricably linked.
It is an easy trap to fall into to try to break down a perennial safety problem into its smallest possible parts. But in the process, you run the risk of breaking the system into pieces that don’t reflect the reality of how each facet interacts to influence the delivery of care. Only when we design the system for the patient and the healthcare worker, instead of having the workforce conform to the system, will we finally see meaningful change and safer care.
#2: Overlooking human factors engineering
Too often in healthcare today, we build systems and processes and then insert the humans, whether it be the frontline staff or patients. Instead, we need to build system components and processes to support the people who will interact with them.
A system should not require people to consistently perform at levels that stretch their capabilities. Many healthcare facilities are operating with workflows that exceed the capacities of its people, through no fault of their own.
Human factors engineers specialize in understanding how the design of a system creates opportunities for human error. From their perspective, human error is an impetus to find weaknesses in the system so that safety and performance goals can be met.
For example, human factors engineers might respond to infusion pump programming errors by redesigning the layout of an EMR screen so that the information needed to program an infusion pump is arranged in the same order that those fields display on the pump. They might respond to glucometer use errors by designing blood glucose test strips that cannot be inserted upside down or backwards.
We will never be able to remove all human error from healthcare. Humans will fail. However, we can drastically improve the design of healthcare systems, workflows, patient pathways and clinical practices with a human factors engineering mindset to reduce the frequency and negative consequences of errors.
#3: Stifling “Just Culture” in the workforce
It is well-documented that healthcare organizations with a positive safety culture (where safety is a shared priority) have overall better safety outcomes. That is much easier said than done when faced with the urgent need to lead a culture shift and execute the strategies that are the hallmarks of a “just culture.”
When frontline staff are too fearful or not empowered to speak up, critical issues go unreported. This silence contributes to a cycle of errors that could be preventable. In a just culture, the healthcare workforce is encouraged and rewarded to report mistakes, near-misses, and safety concerns without fear of punishment or blame.
Just culture balances accountability with learning, by differentiating between unintentional mistakes, at-risk behavior like shortcuts or workarounds, and reckless behavior.
Honest mistakes should be seen as opportunities for learning and improvement, fostering a focus on system-level issues rather than individual blame.
Whether you’re the leading physician or specialist, or a new nurse at the patient’s bedside, everyone in the system must be empowered to speak up – quickly and uncensored – about a near-miss, adverse event, or process improvement.
# 4: Ignoring health inequities
Consider the very real and pervasive health inequities that plague our healthcare system. Due to race, ethnicity, gender, degree of disability, socioeconomic status, religion, veteran status, and sexual orientation, patients could receive considerably worse healthcare and suffer higher rates of preventable harm. Minority patients are more likely to experience an adverse event in the hospital – and providers are significantly less likely to report harmful events for minority patients.² ³ ⁴
It is unacceptable that access to quality care can be influenced by race, income, or zip code. These disparities are not accidents, whether in maternal mortality, chronic disease management, or other areas — they are the result of explicit and implicit bias, and systemic failures that prioritize profit over people.
No clinician goes into work and intentionally chooses to treat a patient differently based on their background. Yet it happens every day. Even the technologies and tools we use to deliver care can fuel inequitable outcomes. We cannot solve a problem that people don’t believe exists – so it starts with awareness within our institutions, and self-awareness among clinicians, that health inequities are real, pervasive, and catastrophic.
We simply cannot improve patient safety without addressing health inequity. It’s our moral imperative to demand change and advocate for access to quality, safe care for all patients. We must dismantle the systems and practices that perpetuate these injustices and build equitable health solutions that leave no one behind.
A holistic, total systems approach, driven by clinically-informed human factors engineering principles, is essential for us to truly achieve zero preventable harm. Strong patient engagement, a drive to reduce health disparities, and just culture are hallmarks of this successful, proven approach.
It is time to be candid with a sense of urgency to scale solutions that improve safety outcomes. The journey to eliminating preventable patient harm and ensuring equitable access to care begins with acknowledging we have a problem. We simply cannot accept the status quo. The time to act is now!
Resources for Healthcare Leaders
- Understanding “Human Factors” is Not “Factors Associated with Being Human”
- Racial and Ethnic Disparities in Health and Healthcare: ECRI and the ISMP Patient Safety Organization (PSO) Deep Dive
- Total Systems Safety (TSS) Resource: Applying TSS principles to address ECRI’s Top Ten Patient Safety Concerns of 2024
- Just Culture and Its Critical Link to Patient Safety (Part I) – ISMP
- A Culture of Safety in Senior Care – ECRI
About Dr. Marcus Schabacker
Prior to joining ECRI as President and CEO, Dr. Schabacker was an anesthesiologist and intensive care specialist whoserved patients in complex care settings around the world. He also held senior leadership roles in the medical device and pharmaceutical industries across the healthcare value chain for more than 20 years. As his career progressed, he was increasingly alarmed at the prevalence of preventable harm – and the impact of often profit-driven voices in the delivery of care, be it on the industry or provider side. These experiences brought him to ECRI. Read full bio.
Contact
Yvonne Rhodes, ECRI Associate Director of Strategic Communications, at YRhodes@ECRI.org
References
- Bates DW, Levine DM, Salmasian H, et al. The safety of inpatient health care. N Engl J Med 2023 Jan
- Gangopadhyaya A. Do black and white patients experience similar rates of adverse safety events at the same hospital? Robert Wood Johnson Foundation. 2021 Jul
- Thomas AD, Pandit C, Krevat SA. Race differences in reported harmful patient safety events in healthcare system high reliability organizations. J Patient Saf 2020 Dec
- Thurtle DP, Daffron SB, Halvorson EE. Patient characteristics associated with voluntary safety event reporting in the acute care setting. Hosp Pediatr 2019 Feb