dation, the first such initiative in organized medicine.17 As a result of their improvements, some have pegged the death rate from errors in anesthesiology at about 5 deaths per 1 million opportunities, which now approaches Six Sigma level. A recent literature review casts doubts on that level of success,18 though there is broad agreement on dramatic improvements in safety that have led to dramatic decreases in malpractice premiums.19

A core requirement in applying any QI/PHA tool effectively to improve patient safety is to build data, measurement, and control systems around key processes. HACCP demonstrates that every process contains multiple Critical Control Points that will vary, process to process. Two preconditions are necessary to identify Critical Control Points in medical care: first, the identification of core processes, and second, the availability and accessibility of data. Then it becomes more feasible to identify Critical Control Points and to eliminate or minimize hazards.

Since the publication of To Err Is Human, most interventions to enhance patient safety have focused at the institutional level—hospitals, nursing homes, and clinics. As institutions seek to incorporate patient safety initiatives, a key challenge is to win the attention and support of physicians. The identification and control of Critical Control Points in medical care, along with the striking example of anesthesiology, suggest that a parallel—and potentially more successful—approach to rigorous PHA may be through medical specialties and subspecialties in addition to institutional strategies. One clear advantage, demonstrated by the anesthesiology experience, is the potential application of systems improvements on a global basis.

Recent developments in organized medicine support this direction. Brennan reports that the European Federation of Internal Medicine, the American Board of Internal Medicine, and the American College of Physicians/American Society of Internal Medicine have recently outlined a draft physician charter with new major principles and professional responsibilities. The third draft responsibility suggests a new commitment to improve the quality of care not just for individuals but for all patients collectively, a notion Brennan refers to as a new “civic responsibility.” He writes: “The failure of the quality measurement/improvement movement to reach its full potential may reflect the relative failure of the profession to undertake, as a civic activity, the effort to ensure the quality of care defined broadly…. Civic professionalism suggests that the professional should be leading the way, not being brought along by regulations…. For this step, we must likely turn to the various specialty societies…. If we are to be serious about educating practicing physicians about professionalism and quality, we must rely on a strong confederation of specialty societies and groups.”20



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