Patient safety – it’s not embryonic

I had occasion – thanks to a helpful reference librarian at the Lamar Soutter Library at U. Mass. Medical School – to read an entire issue of Clinical Chemistry and Laboratory Medicine devoted to “laboratory medicine and patient safety.”

One of the first things that struck me is that so many articles started out a reference to the Institute of Medicine report on patient safety (1). Hmmm, seems like one of my articles started out this way too (2). I’m getting tired of the use of this reference – in most cases it just boilerplate so that’s ok – but sometimes it’s not. For example, in a section that follows the reference, Donaldson says (3)

“Many adverse event detection systems are embryonic, particularly in the effective analysis of risks and hazards.”

This makes one think that we are just getting started with tools and techniques to reduce preventable medical errors. This neglects the anesthesiology story.

Back in the 70s, anesthesiology had a high preventable medical error rate. Yet, without an Institute of Medicine report or regulations, a group at Massachusetts General Hospital studied why this error rate was so high (4-5), using techniques from aviation. So even 30 years ago, these techniques were not embryonic, they had just not been applied effectively to anesthesiology. Shortly after this initial work, prevention strategies were developed. The only outside event that occurred was a 20/20 television show about the dangers of anesthesiology that aired in 1982 and undoubtedly helped in more widespread implementation of the prevention strategies.


  1. Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington, DC: Institute of Medicine, National Academy Press, 2000.
  2. Krouwer JS Recommendation to treat continuous variable errors like attribute errors. Clin Chem Lab Med 2006;44(7):797–798.
  3. Donaldson L Foreword Clin Chem Lab Med 2007;45(6):697–699.
  4. See;jsessionid=GKGJw17GTqY0NMY8mN6RndvWspLF7n2SstK4FbQr2w2xwF7wTyJh!-9948752!181195628!8091!-1
  5. Cooper JB, Newbower RS, Long CD, McPeek B: Preventable anesthesia mishaps: A study of human factors. ANESTHESIOLOGY 1978; 49:399-406. An online version of Paper 5 can be found at



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