Nor have information systems been used adequately to provide critical checks to be sure that the right patient is receiving the right treatment at the right time. For example, it is entirely feasible to use bar codes to track patients, track medications and provide double checks prior to medication administration. But this technology takes investment, and with declining margins, cash is in short supply for most hospitals.

I am not suggesting that information systems are the entire answer, I am saying, however, that if quality and safety become the number one concern then systems, whether automated or manual, would be better developed than they are currently.

A few years ago, I was working with a university professor in Public Health on evaluating a specific process in a hospital. As we discussed the process we were studying, he kept talking about re-engineering the process. I commented that "one could only re-engineer if the process had been engineered in the first place." He told me I was being terribly cynical. I disagree. I call it realistic. We must begin thinking in terms of systems to insure integration and consistency. Systems reduce errors.

The second issue is how we educate providers about quality and safety. There are 2 challenges here, to teach providers how to work as a member of a team and to teach providers how think about outcomes and not be reactive. Physician education is under cost pressures just like every other aspect of health care. We are expecting more of them to do more with less. Training of physicians is largely hierarchical. It trains the young physician to be reactive rather than reflective. This is dangerous when there is so much to know. Providers also need to learn how to participate in a team and gather information and knowledge from the team. A wealth of knowledge resides within the team about both the patient and about treatment and diagnostic alternatives. No one of us knows as much as all of us. The patient needs all of that knowledge.

These changes will be revolutionary. It is what we need for all of our sakes. The President needs to act, Congress needs to act. And we patients need to demand these changes.

Here's to your health!

The opinions expressed in this article are those of the author only and do not represent the views of the Techman/Kanata or of any of its directors, officers or employees. The author, Mary Decker Staples, can be reached at mdeckerstaples@comcast.net