1. How can we elevate healthcare safety to a fundamental value among all health professionals?

Safety must progress to a system property in healthcare just as it has in other high-risk fields like commercial airline transport and nuclear power generation. But safety as a health system property is not enough. Safety should also be a professional value—at every level of healthcare: internationally;4 5 in health systems; and in every microsystem where patients and health professionals meet. Paul Bate and colleagues propose that “variation” is a sanitized word for “inequality”.6 How can rationalization of unsafe healthcare be replaced with moral distress in the conscience of every healthcare professional?

2. How do we exploit an understanding of context to effect broad transformation?

Patient safety research generally describes what works to improve safety in selected healthcare settings. The question is not only, what works? For most health professionals, it is more accurately the question, what works here? How do we learn to transform healthcare in unique and dissimilar settings? This continues to require deep inquiry into the profound meaning and role of context.7 For example, the implementation of seemingly simple strategies such as hand hygiene for health professionals or pre-operative checklists invariably requires culture change at the local microsystem level. Culture provides an excellent case in point for how local—and yet complex—context can be.8 For instance, measuring safety culture across an institution can provide a high level perspective, but drilling down within an institution demonstrates wide variation (should we say inequality?) in safety culture.9 Saint et al report that when they tried to implement hand hygiene in five Tuscan hospitals, they found variation in the process across institutions, within institutional units, and even between doctors and nurses.10

3. How might medical educators change the subject?

Leape et al address the special place for medical education in the quest for safer healthcare. They emphasise the salutary role of the Six General Competencies implemented by the US Accreditation Council of Graduate Medical Education and the American Board of Medical Specialties. The Competencies place emphasis on the demonstration of practice-based learning and improvement, and systems knowledge. However, Leape et al emphasise that similar preparation is missing in early medical education. Not to put too fine a point on it, but they go so far as to say the current early medical education system prepares “square pegs for round holes”.2

To their list of suggested education reforms, one could add two more high leverage opportunities. First, what are the academic admissions criteria that will demonstrate that an applicant is a committed change agent? How will we encourage students and junior colleagues to question “the way we do things around here” to achieve safe healthcare?11

Second, if we want health professionals to emerge from their early formal education with the knowledge and skills that are needed to achieve safe healthcare, medical schools will need to teach to a broader test. It will include an additional assessment of the knowledge that underpins safe care.12 Good doctors still must acquire solid knowledge of the basic biological sciences for effective care. However, the disciplines that support scholarly inquiry for achieving safe care are found in the social sciences such as sociology, anthropology, and psychology5 and in engineering and organisational theory. These basic sciences also need to find a welcome place in medical schools.

Leape et al provide a fresh call for the will—and an outline of the policies—to achieve the universally safe healthcare that the IOM report demanded. Ten years is indeed a long time. We’re running out of excuses.