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What 'The Pitt' reveals about medicine's patient safety woes
Healthcare's penchant for high-stakes heroics has cost it a productive approach to patient safety and system culture.
When watching HBO's new drama The Pitt, David Marx, an expert in safety culture, wasn't struck by miraculous feats overcoming a medical system that often works against patient safety.
Rather, he was left questioning why the system exists like that in the first place.
"A lot of our healthcare colleagues are like, 'wow, this is the first show that demonstrates what it's really like,' which is interesting because it is so chaotic," Marx, a lawyer and the CEO of the risk management firm Just Culture Company, said in a recent interview. "To some extent, I look at it like, 'okay, you can have a lot of pride, but you shouldn't be put in this circumstance even when the trauma event occurs.'"
It doesn't take a television show to demonstrate that healthcare has a patient safety problem. Although the United States saw nearly a decade of improvement in patient safety metrics prior to the COVID pandemic, the five years since have been slow work in regaining those numbers.
According to a 2024 StatPearls article, medical errors are the third leading cause of death in the U.S., killing approximately 200,000 people every year. A Medicare patient has a 1 in 4 chance of experiencing injury, harm or death when admitted to a hospital, adds patient safety ranking company the Leapfrog Group, and an average of 500 people die from a preventable harm or hospital error each day.
These numbers aren't acceptable, experts agree, but it's hard to determine a path forward to reducing or, ideally, eliminating patient harm. After all, no clinician sets out to hurt a patient or commit a medical error.
According to Marx, the problem isn't the individual -- it's the system.
He and his colleagues at Just Culture have teamed up with ECRI to advocate for total systems transformation in healthcare that's more conducive to patient safety. With a non-punitive approach to medical error reporting and monitoring, ECRI and Just Culture maintain that hospitals and health systems can more efficiently get to the heart of the broken systems that caused the mistakes in the first place.
Design systems around humans' 'inescapable fallibility'
Make no mistake -- humans are fallible. The odds of making a mistake on the job are 100%, and indeed, knowing when, why and how we have made a mistake is integral to preventing another one in the future.
But right now, only 60% of healthcare workers believe their organization responds non-punitively to errors, which can make many fearful of speaking up when one occurs.
That's not just unrealistic, but it's also counterproductive to creating a culture of patient safety. Instead, ECRI and Just Culture advocate for a non-punitive approach to error reporting. This uncenters the mistake and recenters the broken process that might have caused it.
To be clear, the organizations are not saying individuals should be free from blame for egregious actions and neglect. But according to Marcus Schabacker, M.D., Ph.D., the CEO of ECRI, those kinds of egregious actions don't make up the bulk of medical errors.
"We have those two categories where we say we shouldn't be punishing them," Schabacker said in the interview. "One is a true human error."
That might be when a provider takes their eye off the patient for a moment too long or reads a medication order incorrectly. In these cases, leadership needs to know the error occurred and help the caregiver prevent it in the future, but the caregiver shouldn't be penalized such that they are afraid to speak up again.
The second category is "at-risk behavior," or choices people make in good faith without adequate appreciation of risk. These are behaviors or risks people often make because they are in an environment that makes it hard to make the correct or safe choice.
That happens a lot in healthcare, both Schabacker and Marx said. The high-pressure environment that pushes for superhuman perfectionism over fallible human nature often lands providers opting for at-risk behaviors or shortcuts just to get by.
"From a system perspective, we're really trying to understand what is driving the second behavior, the at-risk behavior, because that's where we can be really preventative from a system thinking and human factor engineering perspective," Schabacker said.
Take a mass casualty event, like the one depicted in The Pitt. In the show, doctors and nurses were forced to forego best practices, like properly IDing patients and charting, in place of meeting the demands of treating an influx of patients with serious medical needs.
It was absolutely the right call, Schabacker and Marx indicated, but the scene was also representative of the system built to fail. To prevent the need for clinician heroics and extreme resilience, the pair said the healthcare industry at large needs to build better processes.
Ideally, that would lead hospitals and health systems to build around the fact that their staff and clinicians will inevitably make a mistake. That system would accept human error, coach at-risk behavior and set up a fair disciplinary system for reckless behavior.
"We have to design systems around our inescapable fallibility, not just simply tell people not to make mistakes," Marx asserted. "If we're pursuing zero harm, how do we design the right system? How do we help people make the right choices along the way so that they're not caught cutting that corner?"
To get there, it needs to come from the top.
Leveraging leadership buy-in for patient safety systems
There is no change without leadership buy-in. Culture change from the top facilitates provider trust and cooperation throughout the remainder of the organization.
"It's really starting at the top, creating this understanding that humans will fail," Schabacker stated.
On the surface, it may not sound difficult to cultivate leadership buy-in. After all, patient safety is a critical clinical quality metric, not to mention the right thing to do. Most healthcare organizations prioritize patient safety improvement.
It might not even be a stretch to say most organizations want to create a culture of patient safety, not just move the needle on a metric.
But getting to that patient safety culture by reframing mistakes as non-punitive and revamping a healthcare system that actually builds in the inevitability of failure? That might be a tougher argument to make to leadership, if for no other reason than it could be a costly overhaul.
"You're spending the time and the resources on patient safety already, but you have accepted it as collateral damage for what you're doing," Schabacker insisted. "The top needs to realize that, when we do this, this is not only going to be better for patients; it's going to make us money -- not just save us money."
A total systems overhaul will promote better healthcare quality, drawing in more patients and retaining more clinical talent, Schabacker added.
That talent piece can't be overlooked, Marx said. A culture in which clinical perfection is expected is high-pressure and not conducive to employee well-being.
"It's not only about patient safety but also about employee wellness -- the living in fear that your next mistake's going to cost you your job," Marx stressed. "The consequences are so high that it's not a productive way to provide care."
Healthcare is already on the path toward that more just culture around patient safety, as more organizations focus on a culture of patient safety, a term that usually indicates that non-punitive approach to error reporting Marx and Schabacker described. That cultural overhaul, which also includes efforts to engage patients and families in safety and supporting an agile learning health system, is underway and slowly moving the needle on outcomes.
But there's certainly progress to be made, given the industry's middling statistics on adverse patient safety events and how they coincide with a years-long battle with healthcare worker burnout.
If the industry wants to make that progress, it's going to have to reframe the question, Marx stressed.
"It should be less about the mistakes we make and a more about the choices that we make along the way," he concluded. "How do we make good choices and then hold each other accountable for the quality or choices? It's taking our eyes off the bad outcome, or the mistake, and putting them on the quality of the system we design and the quality of the choices that we make."
Sara Heath has reported news about patient engagement and health equity since 2015.
