Welcome back to the “Believe it or Not” series on Rubin Reflects, where we delve into the intriguing and often unexpected parallels between healthcare and various facets of our world. Today, we’re venturing off the beaten path (quite literally, in a moment) to explore a surprising analogy: healthcare and mountain climbing. On the surface, these two seem worlds apart. Hospitals are sterile, controlled environments, while mountain peaks are anything but. Yet, a closer look reveals a fascinating parallel: both healthcare and mountain climbing rely heavily on preparation, teamwork, and a healthy respect for the unknown.

Healthcare systems are under stress as never before. An ageing population, increasing complexity and comorbidities, continual innovation, the ambition to allow unfettered access to care and the demands on professionals’ contrast sharply with the limited capacity of healthcare systems and the realities of financial austerity. This tension inevitably brings new and potentially serious hazards for patients and means that the overall quality of care frequently falls short of the standard expected by both patients and professionals. The early ambition of achieving consistently safe and high-quality care for all1 has not been realized and patients continue to be placed at risk.

“First, do no harm” is the most fundamental principle of any health care service. No one should be harmed in health care; however, there is compelling evidence of a huge burden of avoidable patient harm globally across the developed and developing health care systems. This has major human, moral, ethical and financial implications. Some key facts:

• Around 1 in every 10 patients is harmed in health care and more than 3 million deaths occur annually due to unsafe care. In low-to-middle income countries, as many as 4 in 100 people die from unsafe care (1).
• Above 50% of harm (1 in every 20 patients) is preventable; half of this harm is attributed to medications (2,3).
• Some estimates suggest that as many as 4 in 10 patients are harmed in primary and ambulatory settings, while up to 80% (23.6–85%) of this harm can be avoided (4).
• Common adverse events that may result in avoidable patient harm are medication errors, unsafe surgical procedures, health care-associated infections, diagnostic errors, patient falls, pressure ulcers, patient misidentification, unsafe blood transfusion and venous thromboembolism.
• Patient harm potentially reduces global economic growth by 0.7% a year. On a global scale, the indirect cost of harm amounts to trillions of US dollars each year (1).
• Investment in reducing patient harm can lead to significant financial savings, and more importantly better patient outcomes (5). An example of a good return on investment is patient engagement, which, if done well, can reduce the burden of harm by up to 15% (4).

Every one of us will be a patient someday, if we haven’t already been one— and we all have family members who have or will need healthcare. What we want out of these experiences is to receive the best possible care, by all definitions. And if we acknowledge that everyone deserves that level of quality, consistency, and comfort, then we have a responsibility as healthcare professionals to pursue what engineers would call high reliability.

What is High Reliability?

The easiest way to answer that is to look at groups that pursue this ideal. Called high reliability organizations (HROs), these entities continuously strive for failure- free operations amid extraordinary levels of complexity and the constant threat of catastrophic error. Air traffic controllers, nuclear submarine operators, and space flight command centers are examples of HROs. The cultures, systems, and processes in these entities are designed to effectively manage the unexpected and mitigate the risk of human error, allowing the entity to go for long periods without any significant issues.

Reliability can be quantified as the number of actions that achieve the intended result divided by the total number of actions taken. Say you have purchased 1,000 cups of coffee over the past four years. In three instances, you did not receive your expected outcome, so the reliability would be (1,000 − 3)/1,000 = 0.997, or a rate of 99.7 percent. The defect rate, or unreliability, equals 1 minus the reliability (1 − 0.997 = 0.003 or 0.3 percent). The defect rate is often expressed as an index based on an order of magnitude. For example, 10–1 means that approximately 1 time in 10, the action fails to achieve the intended result. In our coffee example, the defect rate would be in the range of 10–3, which might be tolerable in this situation but tragic in high-stakes situations, such as commercial airline flight or heart surgery. For most human activity, about 10-3 is about the best level of (un)reliability that can be attained through simple care and vigilance. For HROs, this would be considered the minimum level of acceptable performance for a new organization trying to improve safety and quality. Fully functional HROs attain levels of (un)reliability up to 10-6….one error in a million actions!

While the health care industry achieves high rates of reliability in certain areas, research suggests that our overall reliability rate is not what it should be. In a recent study (5) researchers surveyed patients in 12 major metropolitan areas across the United States to see whether doctors were complying with well-accepted indicators of quality of care. They systematically reviewed charts and did follow-up studies aimed at measuring performance on 439 indicators of care for 30 major medical conditions, both acute and chronic, as well as preventive care measures. Their sobering overall conclusion was that only about 55 percent of the time were patients receiving the care that evidence-based medicine leads us to believe is quality care. In other words, the likelihood that our patients are receiving care that meets the commonly accepted standard we expose in our literature is roughly equal to the flip of a coin. We have an across-the-board defect rate no better than 10–1…….making us less reliable than mountain climbing (see below). Not all of these defects are life threatening, but they leave much room for improvement.

In conclusion, the comparison between healthcare and mountain climbing serves as a stark reminder of the challenges and risks inherent in both fields. Just as mountain climbers must prepare meticulously, work as a team, and respect the unknown to safely reach their summit, so too must healthcare systems strive for high reliability to ensure patient safety and quality care.

Despite the sobering statistics about patient harm, there is hope. High Reliability Organizations (HROs) in other sectors have shown that it is possible to operate in complex, high-risk environments while minimizing errors. The healthcare sector can learn from these organizations and apply similar principles to improve patient outcomes.

The journey to becoming an HRO is not easy, but it is necessary. Every patient deserves the highest level of care, and every healthcare professional has a responsibility to provide it. By striving for high reliability, we can make healthcare safer, more effective, and ultimately, more reliable than mountain climbing.

Remember, the goal is not just to reach the summit, but to ensure everyone makes it back down safely. In healthcare, this translates to not only treating illness but also preventing harm and promoting health for all patients. The climb may be steep, but the view from the top — a world where every patient receives safe, high-quality care — is worth it.

Thank you for joining us on this journey through the “Believe it or Not” series. Stay tuned for more surprising parallels between healthcare and the world around us. Until then, keep climbing!

1. Slawomirski L, Klazinga N. The economics of patient safety: from analysis to action. Paris: Organisation for Economic Co-operation and Development; 2020 (http://www.oecd.org/health/health-systems/Economics-of-Patient-Safety-October-2020.pdf, accessed 6 September 2023).

2. Panagioti M, Khan K, Keers RN, Abuzour A, Phipps D, Kontopantelis E et al. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ. 2019;366:l4185. doi:10.1136/bmj.l4185.

3. Hodkinson A, Tyler N, Ashcroft DM, Keers RN, Khan K, Phipps D et al. Preventable medication harm across health care settings: a systematic review and meta-analysis. BMC Med. 2020;18(1):1–3.

4. Slawomirski L, Auraaen A, Klazinga N. The economics of patient safety in primary and ambulatory care: flying blind. OECD Health Working Papers No. 106. Paris: Organisation for Economic Co-operation and Development; 2018 (https://doi.org/10.1787/baf425ad-en, accessed 6 September 2023).

5.Resar R. Reliability. Presented at the Institute for Health-care Improvement’s Beyond Impact Conference Call; May 19, 2004. Available at: http://www.ihi.org/IHI/Topics/Reliability/ReliabilityGeneral/EmergingContent/BeyondIM-PACTAudioPresentationonReliability.htm.