Safety Doesn’t Happen by Accident

By Tagged:

I hope we can all agree that the tragedy of the Freundel case is the harm that was done to the women who came to him to supervise their conversions. There are important secondary consequences of this episode including undermining faith in rabbis and a general cynicism about Orthodox practice. But the primary issue we must grapple with now is how to prevent this from happening again in the future. If this is done right, reestablishing trust in the Orthodox establishment will follow as a matter of course.

When problems occur in my everyday life, I often rely on my experience as a doctor in the search for solutions. How should one respond when mistakes happen? Errors of commission and omission occur all too often in medical practice. In the past, they were considered an unfortunate but unavoidable cost of doing business of making people better. But over the past two decades, with increasing attention to quality of care, there is a growing unwillingness to accept medical error and poor clinical outcomes as an inevitable part of patient care. Root cause analyses are routinely implemented after a bad outcome in an attempt to identify the conditions in the health care delivery system that led to the problem. This, in turn, can lead to the implementation of procedures to prevent errors from happening again and ensuring patient safety.

The looming health problem that dominates the news is the Ebola outbreak. After the first case was diagnosed in Dallas, there was widespread recognition that the hospitals and doctors were unprepared. Mistakes were made on the local and national level and patients and health professionals were harmed as a result. However, physicians and public health officials worked hard to devise better strategies to treat patients, identify exposed individuals at risk of developing Ebola, and draft improved procedures to protect patients, health care providers, and the public. This project is far from over and it is unclear whether the Ebola outbreak will be successfully contained. But as far as I can tell, no one has questioned whether a multi-disciplinary approach with multiple layers of oversight involving doctors, researchers, ethicists, public health officials and others is required to treat patients, reduce population exposure, develop new therapies, define the role of clinical trials, and determine the best utilization of resources. There may not always be harmony but everyone recognizes the need for all stakeholders to be involved in this corrective process if mistakes are to be avoided.