Archives for Amory Codman

A Century of Patient Safety

The history of patient safety as an organized movement has been a century in the making, beginning with the American College of Surgeons hospital standardization campaigned, launched at a Chicago conference on October 19, 1917.  A narrated video presentation on the movement’s early years is available above and the transcript follows below.  

In the 1990s, errors in health care had patients dying at a rate equal to a jumbo jet crash a day, according to a Harvard study.  Giving these patients real names and compelling stories, high profile media coverage of particularly tragic errors made the human cost and the need to act unavoidable.  The American Medical Association responded by launching the National Patient Safety Foundation. There was a sense of urgency and it may have seemed new, but it really wasn’t new at all. Rather, it was a renaissance.

The fact is, patient safety as an organized movement began a century ago in 1917.  That October, the American College of Surgeons launched its effort to standardize the nation’s hospitals for greater efficiency.  For them, hospital efficiency meant losing fewer lives to inaccurate diagnoses and incompetent surgeries.  They called on the nation’s hospitals to institute patient record systems, follow up on results, organize physician staffs, and establish laboratories.  The surgeons would check up on hospitals annually, publishing lists of hospitals meeting their standards.

The story begins on October 19, 1917.

Opening the pages of the Cincinnati Enquirer, we find a short article about the superintendent of Cincinnati’s General Hospital Dr. Arthur C. Bachmeyer.  He had left the previous evening for Chicago and a conference convened by the American College of Surgeons to make operations safer.   Inspectors would later fan out across the country, “checking up” on hospitals to see if they met minimum standards.

Also attending the conference was Amory Codman, the Boston surgeon considered by many the father of patient safety. He had developed an innovative record system, one card to a patient, documenting the end result of each case.   Using the cards, he summarized errors and failures.  He asked:  “was it the fault of the surgeon, the disease or the patient.  What can we do to prevent similar failures in the future.

Codman believed patients were put at risk by a rigged promotion system that overlooked the best surgeons.  Based instead on seniority, advancement came to those who built careers on connections and personal reputations, not on results.  In a very undiplomatic move, Codman made his point with a large cartoon drawn by an artist friend – fully in the style of a muckraker exposing corruption — which he unveiled at a public medical society meeting with reporters present.  As result, Boston society ostracized him while, across the nation, many heralded him as a patient safety pioneer.  In fact, the Joint Commission until recently presented an annual Codman award.

Meanwhile, patient safety borrowed from other movements, including Teddy Roosevelt’s conservation movement. Conservation came to mean more than protecting nature.  It also meant protecting human life.  In Atlanta, the newspaper reported that conservation of human life would be the focus of a public meeting on hospital standardization sponsored by the American College of Surgeons.  It urged its readers to attend.

Efficiency was another, “borrowed-from” movement. The most famous of the efficiency experts, Frederick Taylor, focused on factories.  But, Amory Codman’s friends, Frank and Lillian Gilbreth – of Cheaper by the Dozen — concentrated on bringing scientific management to the operating room.  In fact, Frank Gilbreth spoke at the same meeting where Codman presented his controversial cartoon.  Codman said “There’s a general movement, which the public is beginning to demand, toward increasing the efficiency of hospitals.”  Greater efficiency meant better safety.

The surgeons weren’t alone in promoting standardization. Henry Ford got in the act too. You could have your Model T in any color so long as it was black!  For the surgeons, efficiency was the standard. They said hospital standards “are as figures of a barometer which indicate the degree of efficiency of a hospital or the degree of safety of a hospital to patients.”

Correct diagnosis was Richard Cabot’s passion. He and Codman were friends and, like Codman, he was a reformer.  He published controversial studies reporting diagnoses were more than half-wrong. In partnership with Ida Cannon, pictured here, sent social workers from Mass General into the community, to improve conditions and to follow up on the results of care.

As far as Codman was concerned, surgeon efficiency reports were like batting averages. An amateur baseball player, he believed medicine needed rules and umpires.    Quite to the contrary, Arthur Bachmeyer, the Cincinnati hospital administrator believed great teams won championships even without any star players.  What mattered most was the organization, not the individual.

Teamwork was a constant refrain, like standardization and efficiency. To be up to standard, hospitals had to conduct monthly hospital staff meetings dedicated to reviewing and preventing errors. Pictured here is the St. Louis Children’s Hospital staff of the time.

Hospitals also had to keep records. The editor of Modern Hospital, John Hornsby wrote, if good records are kept, good work will be done, but 75% of hospital records had no value.  When Bachmeyer presented a set of recommended forms at the American Hospital Association, his report was hailed.

Speaking for nurses was Carolyn Gray from, as she said, “the applied common sense department or safety first division. Writing or printing orders spells safety for the patient and after all that is the acid test.”

Catholic hospital sisters got their written orders, quote “with a sister in charge having full authority to demand the careful cooperation of doctors, interns and nurses.”

When the nation entered World War I, many top physicians, surgeons, nurses, and administrators joined the army or navy. Patient medical records and monthly hospital reports, including documentation of errors and mistakes, were mandatory.  In this photo we have – in uniform – the Mayo brothers, Albert Ochsner of New Orleans and George Crile of the Cleveland Clinic.

Organizing and staffing their own battlefield hospitals were America’s leading medical schools and hospitals. Here is the Washington University base hospital in France.  The American College of Surgeons executive director John Bowman, wrote in the New York Times,  “Military hospitals are now standardized for soldiers so is the best surgery too good for the humblest patient? Are mistakes due to carelessness not repeated?”

About half the men examined for Army induction were rejected for defects. The surgeons saw standardization as a solution.  In fact, it was a test of medical patriotism.

Hospital fund raisers promoted the standardized safety of their new hospitals. Between 1925 and 1929 nearly a billion dollars was spent on new hospital construction, a third of all hospital capital investment by the end of the decade.

By 1928, the American College of Surgeons declared their hospital standardization campaign a great success.  Hospitals were safer.  Hospital mortality had been cut by half to 5%, from about 10% a decade earlier.

Meanwhile, auto crashes were sending drivers, passengers, pedestrians and an alarming number of children to the hospital. Cars were the fifth leading cause of fatalities. The surgeons and the auto club joined forces in a new campaign:  Safety first (when driving)/Safety afterwards (if you have to go to the hospital) The auto club provided lists of approved hospitals to its members.

Sadly, optimism over safer care came crashing down in 1929 when x-ray film at the Cleveland Clinic caught fire, costing 123 lives. It turns out that the Cleveland Clinic was not considered a hospital and thus not part of the surgeon’s safety program.  Responding to newspaper reporters, the American College of Surgeons said it had warned about the dangers of improperly storing x-ray film.

During the depression, the big issue for health care became how to pay for it.  Then came a brutal global war in the 40’s.  In the 50’s, an Ohio court decision stripped charitable hospitals of legal immunity.  Thereafter, lawsuit crises thereafter routinely boiled over.

Fortunately, during these dark ages, the health care equivalent of monks and monasteries labored on.  The Joint Commission took over from the American College of Surgeons.  The American Hospital Association and the National Safety Council collaborated on safety initiatives.  In 1962, the University of Michigan School of Public Health convened a remarkable conference, a beacon in the darkness, alerting hospitals to the hazards of poor safety practices.

Turning on the lights, for good, was the Anesthesiology Patient Safety Foundation with its founding in 1984.  Soon after, the Harvard Medical Practice Study got underway, using patient records from 1984.  By 1997, the National Patient Safety Foundation appeared, launched by the American Medical Association and inspired by Lucian Leape’s revealing research on the high number of deaths caused by medical error.  The patient safety renaissance had begun.