Editor's introduction: Patient care and safety

Article Outline

• Copyright

In this issue of the Journal of Critical Care (JCC), Peter Brindley argues that medical “crashes” deserve more rigorous attention, analysis, and strategies for prevention than have been provided previously. Analysis of error presupposes an understanding of its morphology, provenance, and psychology, areas in which the medical profession is, regrettably, lacking. It is apparent that medicine is the ultimate team sport, requiring ever-increasing performance from disparate individuals involved in an intricate and complex series of actions that increasingly are interdependent and require flawless execution to ensure desired outcomes. System failure in a small area may result in an inappropriate or failed administration of a scheduled medication or treatment that has negative consequence. The concept of the “Swiss cheese” alignment permitting adverse outcomes has been discussed for many years, and the importance of interpersonal and communication skills resonates in the form of a “core competence” in graduate medical education. Yet the inability of medical professionals to reintroduce themselves to one another before embarking on a complex procedure is the norm rather than the exception, despite administrative exhortation and checklist preparation to the contrary. There is little doubt that the individual practitioner cannot survive in isolation; and recent GE advertising during the Olympic Games suggests that an individual patient's care becomes synonymous with an integrated and team-focused effort that does not eliminate the final physician transfer and responsibility, “Thank you, I've got it now.”

The importance of an aviation model and solution remains to be validated, although common sense indicates its value and underscores the importance of the safe and “friendly” skies. An objection, however, must surface if we underestimate the importance that responsible individuals derive increased functionality and improved outcome from including additional resources (people) and “aides memoires” (checklists). The isolated physician as an independent practitioner is a concept as nonfunctional as an airline schedule without air traffic control. The message is clear: a behavioral change in the manner in which medicine is practiced is necessary, solutions are rampant, the methodology for implementation is confused, and an understanding of the necessity of transformation is variably understood and accepted. It is in this context that Bindley's comments should be explored.

The articles selected for inclusion in this issue reflect continued commitment to provide content that underscores the importance of integrating clinical practice guidelines into routine patient management to improve results, the importance of analyzing therapeutic outcomes to enhance their success, and the recognition that ongoing translational research is necessary to secure therapeutic advances. The Journal's continued focus on electronic content increases the availability and timeliness of important information heretofore unavailable in a print-only forum. This issue introduces access to a leading article for download by nonsubscribers to expand global access to key content.

The Journal will seek to understand and proselytize the most effective methods to deliver and teach the highest-quality critical care possible in the unique environments in which it is practiced. This requires an understanding of the political environments in which critical care is practiced as well as the more recognized resources necessary for its delivery. This will differentiate JCC's content and create a forum in which international problems can be explored and their necessarily adaptive systems understood, improved, and ultimately shared. If the Crew Resource Management model has become the adaptation that recognizes the importance of teamwork to fuel improvement in aviation safety and efficiency, then improved communication between all members of the critical health care team, irrespective of resource allocation, is a fundamental and internationally available resource. We are increasingly aware of areas in which error can be reduced, yet it is apparent that we are unable to learn and apply simple lessons that can effect change: hand-washing (now hand hygiene in a more politically correct and appealing version), information (and insight) integrity when transferring patient care between providers, checklists to ensure error- and infection-free insertion of central lines, understanding the importance of eliminating inappropriate abbreviations and trailing zeros, etc. We understand the reasons and logic behind the requirements; yet wrong site/side surgeries remain a concern, drug delivery errors abound, and health care is rated in a safety category comparable with bungee jumping.

Behavioral change is one area that is immune to resource allocation and independent of device sophistication; it is entirely team driven. It is an imperative to understand globally available resources that ensure the most effective care delivery possible to the individuals entrusted to critical care systems irrespective of funding and sophistication. Ultimately, it will be the provider at the bedside who creates the environment; JCC intends to provide a resource that ensures ready access to enabling information to ensure patient safety.