Sunday, 8 May 2016

Will we ever give patient safety the attention it deserves?

This week the British Medical Journal published a report by renowned patient safety champion Marty Makary which examines the role of healthcare error on mortality. 

Healthcare error take many forms, including :
  • ·      Unintended acts (either commission or omission)
  • ·      Execution errors
  • ·      Interpretation and synthesis errors
  • ·      Planning errors, and
  • ·      Deviations from processes of care

The report highlights the lack of visibility surrounding healthcare error.  Annual causation mortality data is often compiled from death certificates and coding, based on classifications such as the International Classification of Diseases (ICD) code.   Such systems do not routinely account for healthcare error, and so do not feature on such annual lists.

The fact that healthcare error results in patient deaths comes as no surprise to most practicing clinicians, many of whom have either witnessed patient deaths related to management errors, or even been a part of the process themselves. And it’s not a pleasant experience.

What should be startling is that the issue has been recognized for so long, yet little progress seems to have been made.  It’s now over 15 years since the seminal work of Lucian Leape and colleagues (1) highlighted as many as 98 000 American lives are lost each year related to iatrogenic factors in hospitals, with countless more injured.  Many of these deaths are thought to be potentially preventable.

Despite the furore that Leape’s To Err is Human report generated, little seems to have changed.  Subsequent reviews (2-6) have since estimated that between 200 000 and 400 000 US deaths can be connected to patient error annually.

Extrapolating the published literature, Makary and colleagues suggest that, if true, iatrogenic causes of death would rank third on the all-cause mortality table in the US (behind heart disease and cancer).

It’s hard to imagine that if healthcare error was viewed as a disease, widespread public awareness campaigns, fundraisers and dedicated research would be inevitable.

No one who works in healthcare could possibly suggest that a zero patient death rate due to iatrogenesis is possible.  The healthcare system is almost as complex as the humans it cares for.  It’s clear that the vast majority of patients who traverse the system are well cared for by highly motivated and caring individuals, and the results are usually positive.

That notwithstanding, healthcare needs to re-evaluate its approach to safety.  The external perception of the acute care industry is that of a High-Reliability Organization, where safety is prioritised against all other factors.  Industries such as oil and gas exploration, aviation, and nuclear power have demonstrated that this approach can reduce injury to almost zero.

The serial failure of our industry to embrace standard, risk averse behaviours contributes greatly to the harm it generates :

·      Failure of orientation
·      Failure to validate procedural competence
·      Failure to ensure equipment familiarization
·      Failure to embed policy and procedural change
·      Failure to embrace literature and national standards
·      Failure to embrace technology that can improve and enhance safety standards
·      Safe working hours
·      Failure of process documentation and audit
·      Communication failure
·      Failure to measure and report outcomes transparently
·      Failure to ensure critical incident learnings are widely distributed
·      Failure to report and investigate “near miss events”
·      Failure to create a no-blame culture

Applying these principles to the healthcare sector will inevitably create tensions and encounter barriers to implementation, but the first step is an acceptance that we can do better.

"I think doctors and nurses and other medical professionals are the heroes of the patient safety movement and come up with creative innovations to fix the problems," he said. "But they need the support from the system to solve these problems and to help us help improve the quality of care."  Marty Makary (source CNN)

About the Author
Dr Todd Fraser is a passionate campaigner for the improvement of patient safety systems.  He is an intensivist and retrieval physician, and is the co-founder of Osler Technology.

1.     Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system.National Academies Press, 1999.
2.     Leape LL, Lawthers AG, Brennan TA, Johnson WG. Preventing medical injury. Qual Rev Bull1993;19:144-9.pmid:8332330.
3.     HealthGrades quality study: patient safety in American hospitals. 2004.
4.     Department of Health and Human Services. Adverse events in hospitals: national incidence among Medicare beneficiaries. 2010.
5.     Classen D, Resar R, Griffin F, et al. Global “trigger tool” shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff2011;30:581-9doi:10.1377/hlthaff.2011.0190.
American Hospital Association. Fast facts on US hospitals. 2015.

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