Patient safety before patient safety: some early pioneers

Throughout medical history there are instances of cures that proved worse than the disease, of terrible suffering inflicted on hapless patients in the name of medicine, and of well-intentioned though deeply misguided interventions that did more harm than good. Think, for example, of the application of mercury and arsenic as medicines, bleeding cures, and the widespread use of lobotomy in the 1940s.

Doctors, nurses, and other health professionals have always been conscious of the potential for harm and, on an individual basis, tried to ensure the safety of their patients. However, patient safety, in the sense of a systematic approach to the study, prevention and amelioration of harm to patients is generally thought to be a modern phenomenon first coming to prominence around the time of the new millennium. Some of the essential ideas and practices however can be discerned well over a century ago. This first article describes the work of some of the isolated pioneers who, often in the face of fierce opposition, drew attention to the harms of medicine and took action to protect patients. A second, companion article, considers the evolution of patient safety in its modern form.

Florence Nightingale and hospital acquired infection

In the 19th century, dangerous treatments were one form of harm. However, hospitals could also be secondary sources of harm, in which patients acquired new diseases simply from being in hospital. This is closer to our modern sense of patient safety. By the mid-19th century, anaesthesia had made surgery less traumatic and allowed surgeons time to operate in a careful and deliberate manner. Infection however was rife. The term ‘hospitalism’ was coined to describe the disease promoting qualities of hospitals, and some doctors believed they needed to be periodically burnt down. In 1863 Florence Nightingale introduced her Notes on Hospitals as follows:

‘It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm. It is quite necessary, nevertheless, to lay down such a principle, because the actual mortality in hospitals, especially in those of large, crowded cities, is very much higher than any calculation founded on the mortality of the same class of diseases among patients treated out of hospital would lead us to expect’

Florence Nightingale (Notes on Hospitals, 1863).

This wonderful paragraph captures a critical feature of healthcare. Everyone can understand that flying or drilling for oil is inherently dangerous, but how can healthcare that is intended to help us end up causing harm? It is strange, seemingly paradoxical, that caring can produce harm. This is however not just an emotional appeal, but one backed by data and an early use of mortality statistics. 

Dramatic evidence of the role of hygiene in infection prevention had already been provided by Ignaz Semmelweiss in Vienna in his study of two obstetric wards. After observing the extremely high death rate of women attended by medical students, Semmelweiss concluded that puerperal fever was caused by conveying putrid particles to pregnant woman during examinations. He instituted a policy of hand disinfection with chlorinated lime and mortality plummeted. Semmelweiss finally published his findings in 1857, after similar findings in other hospitals, but his beliefs were still largely ignored when he died in 1865.

The eminent surgeon Joseph Lister faced similar battles to gain acceptance of the use of antiseptic techniques in surgery, partly from scepticism about the existence of microorganisms capable of transmitting infection. However, by the end of the 19th century surgical gowns and masks, sterilisation and rubber gloves were all in use. Most importantly, surgeons believed that safe surgery was both a possibility and a duty. 

Diseases of medical progress

In the 1920s the potential harmful effects of medicine were explicitly recognised with the introduction of the term ‘iatrogenic disease’, an illness induced by a physician (‘iatros’ in Greek). Initially, the term was used to indicate nervous reactions, such as the anxiety that might be induced by a physician’s diagnosis but later broadened to include other forms of harm. 

By the mid-1950s some doctors, notably David Barr and Robert Moser, were beginning to realise that there were potential hazards associated with the enormous increase in drug use and availability. For instance, Moser pointed out, in his book ‘Diseases of Medical Progress’, that the use of cortisone increased risk of peptic ulcers, infections and osteoporosis.  Barr described some of the major risks, but in the spirit of pointing out that there was an inevitable price to pay for therapeutic advance. Moser’s view was subtly different from Barr’s in that he viewed these diseases of progress as those that would not have occurred if sound therapeutic practices had been employed, an early indication that some medication related harm might be preventable. 

Medical Nemesis

‘The medical profession has become a major threat to health.’ This arresting sentence begins Ivan Illich’s polemic ‘Limits of medicine,’ subtitled ‘Medical nemesis: the expropriation of health’. 

Medicine, argued Illich, was causing harm in three main ways. First, medicine encouraged people to become passive consumers, rather than actively involved in shaping their own health and environment. Second, ordinary suffering and the experience of life and death then become illnesses that required treatment, rather than life to be lived and experienced – the ‘paralysis of healthy responses to illness and suffering’ in Illich’s memorable phrase. Third, medicine was causing direct harm to patients which Illich documented in considerable detail, essentially providing an early overview of patient safety. After reviewing the extant studies on the adverse effects of drugs, accidents in hospital, and the hazards of hospitalisation he concluded that:

‘The pain, dysfunction, disability, and anguish resulting from technical medical intervention now rival the morbidity due to traffic and industrial accidents and even war-related activities and make the impact of medicine one of the most rapidly spreading epidemics of our time.’ 

(Illich, 1977, p. 35)

Illich’s particular contribution to the gradually growing literature on medical harm was in the ferocity of his argument and the challenge he posed to medicine and the medical profession. His claim that medicine caused more harm than traffic and industrial accidents, outrageous and inflammatory at the time, reappears in sober government documents towards the end of the 20th century.

Reflections

We might think that the advances of modern medicine mean that medical harm is now of only historical interest. However, for all its genuine and wonderful achievements, modern medicine too has the potential for considerable harm. As Chantler has observed medicine used to be simple, ineffective, and relatively safe; now it is complex, effective, and potentially dangerous. New innovations bring new risks; greater power brings greater possibility of harm and new technology offers new possibilities for unforeseen outcomes and lethal hazards. 

This realisation provides the foundation, rationale and justification for the evolution of patient safety.