The statistics are well known: 7-10% of hospitalizations include at least one “adverse event”, a broad definition including a variety of mishaps ranging in impact from the relatively benign to a lethal outcome.
Health care systems have been late adopters of proactive policies in the area of patient safety. This delay can be partly attributed to the medical profession’s “cultural” difficulty in admitting imperfection, and facing the reality of the rare, but unavoidable, mishaps and mistakes associated with the provision of health care services. The adversarial tort reform environment in which medical practitioners operate may also be an obstacle to disclosure, by inducing the wrong question: “who is guilty?” rather than “what happened?” No health care professional or worker intends to hurt patients – if this ever happens, the criminal code is the appropriate answer. Adverse events are most often the result of a chain of systemic failures, rather than easily identifiable individual errors. How can we improve the system to promote patient safety?
The airline industry is a good model for health care organisations. Continuous quality improvement and the recognition of operational errors has become an integral part of its culture, even with an incidence of lethal events much lower than what is observed in modern hospitals (1/10 million vs. 1/300). Typically, a pilot will be evaluated for his/her technical proficiency on one hundred occasions over the course of his/her career.
Prevention of adverse events in health care should be guided by 5 key principles: training/simulation, process standardization, check lists, good practice guidance and technological improvements.
Effective action needs strong, proactive leadership indicating clearly the high level of priority assigned to patient safety and patient experience, the two pillars of a patient centered health care system. In practice, this means the nomination of high level executives for each of these sectors, reporting directly to the CEO. Performance indicators should be adopted, guiding the evaluation and promotion of managers. There should be full disclosure of commonly adopted indicators, such as rates of avoidable re-admissions, hospital acquired infections, perforations or retained foreign bodies. Similarly, the results of standardized patient experience questionnaires should be publicly accessible.
Throughout the major C. Difficile outbreak in Quebec (2004-2005), I was struck by the resistance of key stakeholders (organisations and professionals) to the publication of infection rates for each institution. Ultimately, with the classic interventions (hand washing, hygiene, monitoring of antibiotic prescription) public reporting was one of the key factors that allowed us to bring the epidemic under relative control. Recently, after many years of slow progress, Quebec was finally able to deliver the objectives set out in a legislation adopted in 2002: disclosure of adverse events for every institution and a provincial registry for these events.
Promoting patient safety may also require reforming elements of the legal and credential systems. There is still some debate about the medico-legal question of the (yet uncertain) benefits of a “no fault” system. Some advocate for an intermediate solution such as a “no fault” system incorporating an “escape clause”, which would allowing the courts to intervene in the category of “egregious” events ( wrong side surgery, etc). The medical profession should also not shy away from the thorny question of credentialing as the evidence grows that certain categories of rare/complex interventions should be concentrated in expert hands. The challenge here will be ensuring the payment system does not act – again – as a negative counterweight to a necessary policy.
By addressing these system issues, we can truly make patient safety a top priority in the health care system.