Zero harm

zero harm

Zero harm

It’s fashionable in healthcare management circles to talk about ‘zero harm’.  The phrase implies a zero tolerance of anything that might possibly harm a patient, a kind of guarantee that no patient is harmed in this hospital. At its centre is perhaps the idea that if scrupulous care is taken in everything, including the small things, then the big things will take care of themselves.  If we eliminate the possibility for error then no harm can ensue. It’s a bold claim; can it be achieved? 

In some ways, it’s akin to the old medical aphorism, attributed to Hippocrates, ‘Primum non nocere’, ‘First of all, do no harm’.  There are nice differences however.  First, do no harm, means:

  • Do nothing unless it helps
  • Don’t make the patient worse

The principle is non-malfeasance, not intending to harm.  At medical school, students are taught ‘never say never’, if a patient asks, ‘is this dangerous?’.  There is nothing in medicine that is risk-free.

I like another aphorism from a 16th Century French surgeon, Ambroise Paré, who said:

‘Cure sometimes, relieve often, comfort always’.

In other words, as a doctor, you should always be able to do something that makes the patient feel better, even if it’s just holding their hand.

So, I think what people who espouse ‘zero harm’ really mean is ‘zero preventable harm’.


There are well-described cultures and sub-cultures in healthcare organisations.  The ‘way we do things around here’, always trumps top-down instruction.  As Peter Drucker famously said, ‘culture eats strategy for breakfast’! 

Humans make mistakes.  There are two basic types; slips and lapses.  That is, things I didn’t mean to do, but did, and things I meant to do, but didn’t.  As the Anglican Confession makes clear, all human error is summed up by ‘sins of commission and omission’.

Happily, this is where electronic systems can have real impact, since they change the way people interact with one another day-to-day.  Dysfunctional cultures can be modified by the constraint and discipline that electronic systems impose.  A great example is the simple one of legibility of prescriptions.  Every year, thousands of patients are potentially harmed by adverse drug incidents, some of which are simply due to the fact that the nurse couldn’t read the doctor’s handwriting.  Electronic prescribing eliminates this particular risk from go-live.

Electronic systems that alert the user to potential error (‘do you really want to do that?’), such as drug-drug interactions, or prompt the user to take action (‘the oxygen level is unusually low!’) can really help overcome slips and lapses.


Zero harm is really a cultural change aspiration.  Information can drive the change.  If you want to reduce the amount of alcohol you’re drinking, start by keeping a diary of everything you drink.  By making the issue visible you begin to change.  Model the change you want to see in others.  If ‘zero harm’ is really important, then the senior Executives and medical leaders need to demonstrate it, for example:

  • Executive safety ward rounds, asking questions like, ‘What’s not safe around here?’
  • Staff focus groups, ‘when did a patient last come to harm here?’
  • Stop insisting on activities that we know add little value, such as clinical audit!


The more I think about it, the more I feel that ‘zero harm’ is about quality.  There are dozens of definitions, but, ‘Right first time, every time, all the time’, links the two ideas.  Quality is often cheaper, and quality is safer.  Some healthcare organisations are developing a ‘Preventable Harm Index’, which is simply the sum of all adverse events.  There is no denominator, just an absolute number; the aim is to get to zero.