Dr Udayan Barua
(udayanbaruadr@gmail.com)
Patient safety is one of the world’s most pressing healthcare challenges. Without safety, there can be no quality of care. The history of patient safety and quality started with the “first do no harm” call from Hippocrates and the call for hygiene from Florence Nightingale.
Two influential reports, “To Err is Human” (1999) from the US Institute of Medicine and “An organization with a 2000 from the UK government’s Chief Medical Advisor, heralded the start of the global safety movement in the late 1990s. However, the figure of 1 in 10 patients being harmed during treatment is commonly quoted even today in the world of patient safety.
In October 2004, WHO launched a patients’ safety programme in response to a World Health Assembly Resolution (2002) urging all member states to pay close attention to the problem of patient safety. In 2019, an important landmark resolution, ‘GLOBAL ACTION ON PATIENT SAFETY’ was adopted by the 194 countries that participated in the 72nd World Health Assembly held in Geneva. As a result, the 17th of September 2019 became the first “WORLD PATIENT SAFETY DAY “. Every year, this day will be dedicated to promoting public awareness and engagement, enhancing global understanding, and spurring global solidarity and action. The aim is to engage all categories of people involved in providing care to patients, including healthcare workers, policymakers, academics, and researchers, as well as professional networks and the healthcare industry.
Modern healthcare organisations are enormously complex. Even the most routine tasks in healthcare depend on a complex system that involves multiple people, activities, and technologies. For example, a typical patient in an intensive care unit requires 178 separate actions to be performed for him each day by a range of people, and a terminally ill patient will typically be treated by at least 5–10 specialist doctors. Many factors, such as effective communications with colleagues, the staffing level, available resources, the design of the hospital, the quality of equipment, and high-standard information technology, are some of the important requirements to deliver safe and quality healthcare.
Safety improvement efforts need to be targeted at improving the system. Minor errors and mishaps in one area of a system are not confined to that area but can impact activities in other areas in unexpected and dramatic ways. For example, a simple decision about adding a cleaning agent to a hospital’s water system in the UK (2008) led to the death of one haemophilia patient and serious effects on four other patients requiring blood ransfusions. It was not realised or fully communicated that renal unit water filters could not remove that particular chemical, which passed straight into patients’ blood streams.
It is an unfortunate truth that the prevailing culture around serious incidents in healthcare remains one of blame. When a serious incident occurs, the first priority is obviously the care of the patient and family. The second priority should be supporting colleagues and not rushing to blame or condemn people who make mistakes. It is true that some types of behaviour deserve blame and sanctions, but even the best people make honest mistakes. When this happens, they need support from both colleagues and their organisation, both for their own well-being and for the sake of the patients they will be looking after in the future. We need to understand the nature of error and, in particular, how working conditions strongly influence our behaviour and likelihood of error. A recent report demonstrates the influence of work system factors on residents’ well-being. Forty-five to sixty percent of medical residents experience symptoms of burnout, which is characterised by high emotional exhaustion, high depersonalisation, and a low sense of accomplishment and worth. In particular, electronic health records (EHR) are identified as a source of burnout in 75% of cases due to increased clerical and documentation burden.
Some branches of medicine, most notably anaesthesia, have been at the forefront of developments in patient safety. Human factors are a core theme in the postgraduate curriculum for anaesthesia training, and many quick reference handbooks (like military and civil aviation) have been developed as cognitive aids for diagnostic challenges, particularly during rises. Similar training must be extended to undergraduate and nursing schools. It is only by ensuring that young professionals in healthcare are equipped with the necessary tools to understand the complex and rapidly evolving systems in which they will be working to improve patient safety that
In an era when the human genome has been mapped, when air travel is safer than ever before, and when information flows across the globe in seconds, patients cannot be fully reassured of zero harm during healthcare delivery. Despite the extensive work that has been done at the global level and in health systems around the world, a sustainable model for safe healthcare is not in place. The scale of the problem is so great that the problem of patient safety needs to be everybody’s business. It is essential that health systems are built with patient safety and quality of care as their organising principles.
Any assessment of the prospects for creating much safer healthcare systems and health facilities everywhere will be bound to conclude that it will be a long journey. A clear consequence of this is that it cannot be entirely achieved by the current group of senior patient safety leaders. Their successors need to be grown, mentored, and inspired to take on the mantle of future leadership as well as be properly guided for day-to-day clinical work. The first international meeting, “Patient Safety for the New Medical Generation,” which took place in Florence in 2018, was a right step in this regard. The priority is to train all those serving at the coal face of healthcare delivery to have the capacity to be barometers of the quality and safety of healthcare provisions.