Journey to Zero

April 19, 2021

What is the acceptable number of people to be harmed by healthcare?

When I started my pediatric training in the mid-1980s, my answer would have been “what are you talking about?” No one was talking about patient safety.  To the extent we acknowledged medical error, it was that there were some “bad apples” who committed malpractice, but not a huge issue.  And of course, people did sometime make mistakes – humans aren’t perfect after all – but that wasn’t really a problem, just an unfortunate fact we had to accept as the price of advanced medical care.

Then, in 1999, the Institute of Medicine published a landmark report, “To Err Is Human,” that showed that medical error is in fact rampant and preventable.  Tens of thousands of Americans were dying each year at the hands of those who intended to help them.  Not because those were bad people, but they were operating in imperfect systems.  Healthcare is complex, and like any complex system, failures can occur.  Yes, to err is human.  But the answer isn’t to accept error as a necessary evil.  It is to design systems that prevent error from occurring despite human failings.  The answer to the question I posed at the top is “zero.”  It’s never acceptable.  Which is why our patient safety effort at Children’s Minnesota is called Journey to Zero.  Our goal is that no one is ever harmed by the care we provide.  We aren’t there yet, and maybe we’ll never get all the way to zero.  But at least theoretically we can improve our systems to the point of no harm, and we won’t stop trying until we do.

The idea is to design the system to make it as hard as possible to make a mistake, and as easy as possible to do the right thing.  Consider such incredibly complex, high-risk, and high-stakes industries as nuclear power and aviation.  “Routine” airplane crashes and nuclear plant explosions would not be acceptable, and they don’t happen.  These industries are not perfect, but they are getting awfully close to it. They have developed a set of principles and practices that have been borrowed by healthcare to make our systems better and avoid preventable harm.  Tens of thousands of people area alive today who might not be if healthcare hadn’t followed their lead.

OK, let’s switch to a different topic.  What is the acceptable number of Black people to be harmed by law enforcement?

Police killings of Black people are really not that different from plane crashes or medical errors.  The law enforcement system isn’t trying to kill people.  It doesn’t want to kill people.  It doesn’t have to kill people.  And yet it is killing people.

And the problem isn’t “a few bad apples.”  The problem isn’t “mistakes are made.”  The problem is the system.  It is a system whose harm is disproportionately affecting Black people, the definition of systemic racism.  But it’s a system in denial about the nature of its problem.  Like healthcare in the 1980s, it relies on an adversarial approach to identify individuals to blame for bad outcomes.  Not only does this not solve the problem (as I said in regard to healthcare, even skilled and well-intentioned individuals can and do cause harm in an imperfect system), but it creates an environment in which calling out the problem is seen as a personal attack and it elicits a defensive response.

Our law enforcement system needs to start a Journey to Zero.  It needs to acknowledge that police killing of Black and other people of color is a systemic failing, and embrace systemic change.  As in healthcare, law enforcement needs to create a culture of safety, elements of which include:

  • shifting away from assigning blame to an individual, to identifying root system causes for harm.  Some root causes here might include officers who are not part of the community they serve; emphasis on the use of force as an early, even preferred, means of addressing conflict; and failure to address ingrained attitudes and biases that portray Black people, especially Black men, as an inherent threat
  • empowering and incentivizing all to speak out, regardless of position in the hierarchy, and report problems rather than ignoring or covering them up
  • transparency about progress or lack thereof, with accountability at all levels

When we post the number of CLABSIs on each nursing unit, it’s not meant to shame the clinical staff.  When a staff member enters a safety learning report about a near-miss medication error, they get a thank you note, not a reprimand.  Similarly, if we talk about the need for reform of law enforcement, I hope that is seen as a criticism of policing, not of individual police. Over the last 4 years, an average of 227 Black people have been killed by police annually.  This is equivalent to a Boeing 757 crashing each year, every year.  It’s time to start that Journey to Zero.

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