Insights (Essays)

Insights (Essays) December 2013

Why Are We Still Looking the Other Way?

Dr. Charles Low and Hugh MacLeod

Are we all on the “balcony of personal reflection” looking the other way? There is ample evidence that when patient safety is successfully administered, lives are saved, long-term adverse events are prevented, and the overall financial toll on the system is decreased.

Subsequently, there is sufficient evidence which attests that the implementation of patient safety is incredibly slow, erratic and sub-optimal. Regardless of the available patient safety data at our disposal, the overall population statistics remain unchanged. Patients continue to suffer preventable deaths and mishaps, and at a pace that would be deemed unacceptable by any other industry.

Why is there little discussion surrounding these present inadequacies which are responsible for sustaining these significant yet preventable errors?

The Ghost of Consciousness suddenly appears:

“Do you really need me to answer your question? It is human behaviour at its finest. Our habitual patterns facilitate our daily actions thus narrowing imperative change down to “maybe one day” or “but I know better.” Knowledge will only take us so far; the success of patient safety hinges on one’s ability to not only comprehend the importance and magnitude of patient safety but to understand their own individual role and contribution within it. The entire culture of healthcare must change; both the patient and healthcare provider must progress beyond a submissive/complacent condition.” 

The journey ahead will be long and arduous, and at times it will simply seem too overwhelming to contemplate, especially when everything in the system continues to morph. The system will never be static; it continually evolves with every new bit of information and technology. Patient safety is not an end result but rather a continual characteristic of the system as a whole. Therefore, it is essential that the seeds of patient safety are sown, allowing patient safety to be deeply ingrained within the root and overall development of the system. 

Consider the following, acknowledging the implicit generalizations:

  • Within the patient safety movement, we tend to focus on procedures, while our real challenge is culture. The failure and temporary fixes are largely due to our failure to address culture.
  • Cultural transformation is talked about, supported by past literature and experience, and yet often not done well. 
  • Those within patient safety are not well-trained in cultural transformation and they have not sought out those individuals that are.
  • We acknowledge that effective, system-wide change has to be supported from the top, but have confined our thinking to jurisdictions such as hospitals or regional authorities; their boards and senior management need to be patient safety literate and profoundly committed. In Canada, however, the very top is the ministries of health at federal, provincial and territorial levels. Patient safety narrative is often absent or separate from the access, cost, effectiveness and quality conversations.

Incremental steps and procedures must be implemented in order to gain traction within the culture of healthcare. Perceptions and attitudes will only be shifted when protocols are supported by education, leadership, reporting and other compliance measures.

If we wish improvement at a population level, then we must work at a population level. It may be worthwhile addressing why, to date, we have not done so. Is the head of the system too far removed from its body? We ask you to consider the following factors:

  1. Denial. Those in authority either don’t believe the patient safety reports, find the problem too overwhelming or reframe the data to make themselves look better.
  2. Helplessness. Many people, in the midst of a disaster, feel unable to make their voices heard. Some never try, while some make an effort but eventually desist after numerous (and sometimes quite punitive) rebuffs.
  3. The concept of “it is not my responsibility” and how often that statement is made.

The acts of “denial” and “helplessness” are present within all levels of the system. We must determine how to oppose these factors and transform the defeatist feelings held into feelings of acceptance and self-awareness.

The towering mountain that lies ahead will remain intimidating for some time, but instead of asking how to conquer it, maybe we should ask how to begin and sustain our ascent. By firmly setting the roots of patient safety and facing our stark reality straight on, we can begin forging our path forward. In the end, much in life seems impossible until it is finally done.

Let’s compare our overall situation with the extreme example of the Mid Staffordshire Trust of the NHS in the UK. See How such high levels of morbidity, mortality and suffering were tolerated for so long is a most heart-wrenching tale.

Three recommendations for your consideration:

  1. Time for a new holistic narrative and conversation. Patient safety is about quality, cost, effectiveness, access, bed utilization, etc. To make population-wide changes, one must work at a population level. Time for a practical conversation including the policy maker.
  2. Patient safety is not being implemented on a widespread basis, let’s change that.
  3. Let’s not underestimate how much patient safety is a cultural rather than procedural change (inexorably linked) and that we struggle with cultural transformations that are very fragile, painstaking and complex. Experts exist on cultural change: let’s engage them.

We close with this passage from the essay, “Courage A Rare Competency”:

“No major public policy arena in Canada is more in demand of courageous leadership than healthcare. What do we mean when we talk about leadership? We believe strong leaders share a number of key characteristics: Insight, initiative, influence, impact and integrity.

“Courageous leaders are able to look at complex situations, gain clarity and determine a course of action. They are willing to go first. They do not sit on the sidelines waiting for a change in circumstances. Strong leaders do not ask others to do what they are unwilling to do themselves. They lead by example. Strong leaders are able to inspire people to willingly follow their ideas. They are able to create real and lasting change. They make a difference.”

Join next week’s conversation titled: “The Road to Harm Paved with Good Intentions – The Patient Experience Matters

About the Author(s)

Dr. Charles T. Low, MD, CCFP, Brockville General Hospital, Department of Anesthesia, Patient Safety Proponent.
Hugh MacLeod, CEO Canadian Patient Safety Institute … Patient, Husband, Father, Brother, Grandfather … Concerned Citizen.


The Canadian Patient Safety Institute (CPSI) exists to raise awareness and facilitate implementation of ideas and best practices to achieve a transformation in patient safety. We envision safe healthcare for all Canadians and are driven to inspire extraordinary improvement in patient safety and quality. To address many of the challenges mentioned in the essay above, the Canadian Patient Safety Institute – with partners – has tools and resources. Please contact


MacLeod, H. and M. Kirby. 2013. “Courage A Rare Competency.” Longwoods Healthcare Ghost Busting Essays.



Charles Low wrote:

Posted 2014/01/17 at 04:47 PM EST

Thanks Hugh for the opportunity to co-write this article with you. Much appreciated.

The question remains: given that we're harming too many people in the actual provision of healthcare, and that we know how to do better, evidenced by an abundant literature and many shining examples, why is implementation actually not even detectable at a population level?

Something is seriously wrong, and my challenge for myself is to do more than write about it.

The form which that "something more" might take however is problematic, but just to leave it at that seems far too defeatist. Ideas welcome. Movers and shakers, please chime in. We need access at the highest levels of healthcare administration.

Who's with me? Our patients need and deserve this.

Charles Low, MD


Rob Robson wrote:

Posted 2014/01/21 at 03:26 PM EST

I agree with you totally Charles. We do need some leadership that is courageous and honest. Should we invite hospitals all across the country to post large signs over all their entrances that warn patients of the risks of being admitted - somewhat similar to what is posted on cigarette packages where the risk is actually lower?

The biggest problem, I believe is that we have not discovered how to invite the only people with a real interest to change the situation - namely the patients that we are unintentionally harming. Until we make space for them at the table and then learn to hear what they are saying, not much is going to change.

Of course it would also help if any initiatives we propose faithfully reflect the nature of healthcare as a complex adaptive system.



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