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Safe Expectations

Wagner, Dianne P. MD, FACP; Noel, Mary M. MPH, PhD, RD; Barry, Henry C. MD, MS; Reznich, Christopher B. PhD

doi: 10.1097/ACM.0b013e3182327c81
Response to the 2011 Question of the Year

Dr. Wagner is professor of medicine and associate dean for college-wide assessment, Michigan State University College of Human Medicine, East Lansing, Michigan.

Dr. Noel is professor of nutrition, Department of Family Medicine, Michigan State University College of Human Medicine, East Lansing, Michigan.

Dr. Barry is professor, Department of Family Medicine, Michigan State University College of Human Medicine, East Lansing, Michigan.

Dr. Reznich is professor of medical education, Office of Medical Education Research and Development, Michigan State University College of Human Medicine, East Lansing, Michigan.

Correspondence should be addressed to Dr. Wagner, Michigan State University College of Human Medicine, A102 East Fee Hall, East Lansing, MI 48824; telephone: (517) 353-8858; fax: (517) 355-0342; e-mail:

Now, I return to this young fellow. And the communication I have got to make is that he has great expectations.

—Charles Dickens, Great Expectations

To improve the health of patients, we must establish a health professions education system in which knowledge of safety science is valued equally with knowledge of the traditional basic sciences. Our health care system today has an adverse event rate approximately equal to that of driving an automobile,1 putting patients at a significant risk. Yet, we have addressed systems improvement education primarily where patient care takes place, rather than requiring a safety-oriented mindset and the requisite competencies of our trainees from the beginning. Health professionals start their training with great expectations, yet soon they become inured to the reality of our unsafe patient care environments.

Patients and their loved ones are not the only victims of medical errors; the professionals giving care are also hurt when errors occur. The stress of working in an error-filled environment decreases our ability to care for and care about our patients—to do what we were trained to do and, often, what we feel we were meant to do. Most care providers began their professional journeys inspired to make a difference in the lives of their patients. Yet, as care providers experience errors firsthand, they realize that the environment is not safe for patients or for those giving care.

If “culture eats strategy for lunch,”2 then we must build a culture in which safety is regarded as a core value and rewarded as such. The hidden curriculum is not hidden; it is reality. Any medical student can answer a fact-based question correctly on a test, but that same medical student will see what actually happens after an error occurs. Any resident can recall his or her residency application essay proclaiming a dedication to putting the patient above all else. Yet, later, that same resident may struggle with maintaining those ideals amidst a chaotic and highly flawed hospital environment. While trainees set out to make as few mistakes as possible, they soon realize that there is no way to avoid errors. The culture of our health care system is one of getting the right answer—who is right sometimes is more important than what is right. It can be a culture of making excuses rather than of expecting strong solutions. Without major changes to the culture of health care, the dream of safety, and therefore better health for our patients, will not be realized.

Inroads are being made—there are calls to action from accrediting and credentialing bodies and new and improved curricular efforts in health education institutions. Many times, these initiatives occur within silos. Yet, sometimes, they span institutions and achieve success. The Michigan Health and Hospital Association Keystone: Intensive Care Unit (ICU) project resulted in a mean of zero catheter-related bloodstream infections in Michigan ICUs.3 What was once thought to be an inevitable occurrence turns out to be completely preventable when the institutional culture is such that it expects solutions to patient safety problems and works tirelessly to make them a reality. Everyone in health care must share these expectations. Until our health care culture expects us all to be a part of the solution to medical errors rather than a part of the problem and intentionally requires that all efforts line up across educational, institutional, and professional boundaries, we won't achieve success.

How, then, do we accomplish these goals? Prehealth professions students might be expected to take courses in system science, human factors, team dynamics, and failure modes and effects analysis. Health professions education efforts must require critical safety-related competencies and assess students' safety knowledge, skills, and behaviors with as much fervor as their knowledge of the Krebs cycle and their ability to determine the differential diagnosis of weight loss. Accreditation of health professions training programs must require the integration of these elements into the formal curricula. Hierarchies within our institutions must be leveled and incentives aligned to reward the achievement of safety rather than profit. Every team member must be responsible for the safety of every patient. These tenets must define our culture as a place with expectations of improved health as well as continuously better care. Health professionals begin their training with great expectations, but until they practice in a culture with safe expectations, health care will never be great.

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1 Amalberti R, Auroy Y, Berwick D, Barach P. Five system barriers to achieving ultrasafe health care. Ann Intern Med. 2005;142:756–764.
2 Collins J. Good to Great. New York, NY: HarperCollins; 2001.
3 Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725–2732.
© 2011 Association of American Medical Colleges