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)
References
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. http://www.providersedge.com/ehdocs/ehr_articles/Patient_Safety_in_American_Hospitals-2004.pdf.
4. Department of Health and Human Services. Adverse events in
hospitals: national incidence among Medicare beneficiaries. 2010. http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf.
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.http://www.aha.org/research/rc/stat-studies/fast-facts.shtml
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