By Dr Solomon Almond

In May 2006 when dreams of their own aeroplane were still maturing in the minds of Barack Obama and Hilary Clinton they wrote a piece on patient safety for the New England Journal of Medicine1.

At the time both had designs on the White House and healthcare is arguably more controversial in US politics than here (at least we all seem to agree on the NHS in the UK).The piece approached patient safety from the perspective of legal costs and insurance. Improved patient outcomes and decreased harm stemmed from improved safety but were not the main drivers.

The Obama and Clinton model dared to propose what to us may sound culturally a step too far for UK tastes; to provide complete openness to patients.

The prevailing culture surrounding patient harm in the UK and much of the developed world is to admit as little as possible and defend malpractice (clinical negligence).

The Michigan University Hospitals approach to openness has had three main strands:

-openly (and even proactively) acknowledge where error has occurred and compensate swiftly and fairly (without large court damages and legal bills)

-staunchly defend spurious claims

-learn from errors and institute system change and learning

By 2005 there were some 4 years experience of the system at Michigan and they had found that claims and time to resolve claims had halved while overall litigation costs were 70% down.

Even more impressive results came from a Kentucky VA (service veterans) hospital that had adopted a similar model in 1987. There was an 85% drop in the cost of each claim and a 90% reduction in the time taken to settle claims compared to comparable VA centres without openness in patient safety culture.

It does at first appear counter intuitive to suggest that “fessing up” to our mistakes and even offering to pay compensation could save money and improve patient care.

There is a range of explanations for the apparent paradox. Defending cases is lengthly and costly; the lawyers take a slice and there are significant internal costs to healthcare institutions.

The Michigan team have argued that the defensive stance towards the majority of claims fosters an intimidating environment where practitioners are understandably reticent to discuss errors.

This in turn acts to limit the learning opportunities and stifle systemic process improvement. The final point was highlighted in the Obama and Clinton piece as they referenced evidence showing 90% of US medical errors were attributable to systems, rather than individual failure.

There is no greater proponent of the open safety culture than the eponymous founder of the Lucian Leape Institute at the National Patient Safety Foundation in Boston Massachusetts.

Whilst acknowledging and praising many patient safety initiatives around the world, including the UK, Lucian Leape commented about developed healthcare systems2:

“Too many healthcare organisations fit James Reason’s definition of the ‘‘sick system syndrome.’’ They are hierarchical and deficient in mutual respect, teamwork and transparency. Blame is still a mainstay solution. Mechanisms for ensuring accountability are weak and ambiguous. Few have the capacity to learn and change”.

The concept of openness in patient safety is starting to reach the conciousness of the UK public. In a recent 2 part radio 4 documentary the area was explored with reference to Michigan and Professor Leape.

Unlike lawyers and politicians (such as Obama and Clinton), we have to approach safety from the clinical direction. It does appear likely that improved patient safety culture can improve patient outcomes as well as keeping financiers and vote seekers happy.

1. Obama BH, Clinton HR (2006). Making Patient Safety the Centerpiece of Medical Liability Reform. N Eng. J Med 354;21


2. Leape L et al (2009). Transforming healthcare: a safety imperative. Qual Saf Health Care 2009;18:424–42