How to Do No Harm

How leaders can minimize harm in health care, in other industries, and in all areas of life.

“How can we change this process to prevent this error from happening again?” the senior ward nurse asked the group. It is a common question, one that I have heard thousands of times from experienced and dedicated health care professionals of all stripes.

I have worked in health care for many years, serving in positions from volunteer to emergency medical technician to senior attending physician to chief of staff at a hospital to chief medical officer of a large network. In every position, “do no harm” is a fundamental theme. This famous statement from the writings of Hippocrates encapsulates quality improvement, patient safety, access to care, and many other goals in modern medicine.

“Do no harm” can be thought of as eliminating risks that could lead to a bad outcome, such as injury or death. Occupational and Environmental Medicine physicians learn that there are four ways to decrease risk in the workplace and in the environment:

  1. Eliminate the risk entirely. We have two inverter generators to use at home and church rather than traditional ones. They are quieter and generate less carbon monoxide, thus eliminating two risks. Taking the lead out of gasoline and paint decreases the chance of lead poisoning, and using nitrile rather than latex gloves helps avoid latex allergies.
  2. Separate the risk from the people. Modern automotive engineers have designed and built cars which nearly the whole car can be destroyed in a crash, but the passenger compartment can stay nearly intact, thus saving the people inside. Hospitals sometimes use devices that automatically retract used needles to avoid needlestick injuries.
  3. Develop administrative controls; processes to minimize risk. “Tickets to ride” ensure the patients are protected before patient transport and “time outs” before procedures minimize the chance of operating on the wrong site, or even on the wrong patient.  
  4. Use personal protective equipment (PPE). Lead aprons in radiology protect patients and staff from radiation exposure. Gloves and mask decrease the chance of infections. In the fire fighting world, bunker gear enables humans to survive and even work in otherwise fatal environments.

The surest way to “do not harm” is to engineer the risk out, and second is to separate people from risk. Neither of these methods require people to do anything, and therefore remove the single biggest point of failure in many safety processes…human error. Techniques 3 and 4 are less reliable precisely because people have to be trained to follow administrative controls and use PPE. Further, people have to follow these controls and use these practices every time and under every condition.

Manufacturing is far more amenable to engineering controls than health care. Producing tires or peanut butter can be broken down into a discrete series of steps which must be done in sequence and in which the production machinery, the rubber, the peanuts, and the other parts of the process can be trusted to behave in reliable ways. In health care, neither the staff nor the treatments nor the patients are equally predictable. That is why health care relies on administrative controls and personal protective equipment, and why we have so many failures…so much risk to patients and staff.

There is, however, another way to minimize the risk of harm, and that is to improve the people. If hazard is thought of as having three components – danger (what can do the damage, like a hepatitis A virus), person (who is at risk), and vector (food and water contaminated with hepatitis A), those who wish to minimize the risk of hepatitis A can attack at any of these points. The Smallpox Eradication Program of the World Health Organization in the 1960s and 1970s, and the modern polio eradication program are examples of attacking the pathogen directly. Purifying the food and water, which commonly transmit hepatitis A, eliminates the vector. Immunization strengthens the person, making them immune to the disease. Simple interventions such as improving diet, exercise, sleep, and mental health improve the person and make disease and injury less likely. Education helps leaders and workers know why they are doing something, and training helps them do it right again and again. Cognitive aids such as checklists minimize reliance on human memory and other sources of failure.

In summary, “do no harm” applies to medicine, but also applies to every other area of life. We can and should engineer harm away, for it is the most effective way to minimize risk to life and health. Vaccines may be considered as a means of engineering harm away. We will attack dangers, block vectors, and strengthen individuals. To “do no harm”, health care professionals will use every tool in the shed, and will use them in a comprehensive and coordinated system. Our patients and our staff depend on it.  

Leave a Reply