March 12th – 18th marked Patient Safety Awareness Week. The World Health Organisation (WHO) estimates that the occurrence of adverse events due to unsafe care is likely one of the 10 leading causes of death and disability in the world (1). In high-income countries it is estimated that one in every 10 patients is harmed while receiving hospital care, and around 50% of these may be preventable. The impact is even greater in low and middle-income countries, with two thirds of all adverse events resulting from unsafe care occur in low and middle-income countries (LMICs) (1).
WHAT IS PATIENT SAFETY?
Patient safety can be defined as ‘the avoidance of unintended or unexpected harm to people during the provision of health care’ (2). It has evolved as a discipline as complexity in health care systems has increased. A key concept is continuous improvement based on learning from errors and adverse events (1).
HOW DO ADVERSE EVENTS OCCUR?
Spiritual needs should be provided if wished for. According to the family’s mind set, culture or religious background, this may involve providing support for their beliefs and values and helping them find meaning and purpose in the face of illness and death.
Some common patient safety issues are illustrated below:
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Medication errors |
A leading cause of injury and avoidable harm; globally cost estimated at US $ 42 billion per year |
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Healthcare-associated infections |
Occur in 7/100 and 10/100 hospitalised patients and high- and low-middle income countries respectively |
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Surgical complications |
Around 7 million surgical patients suffer significant complications annually – some will be preventable |
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Injection practices |
Risk transmitting blood borne viruses e.g. HIV and hepatitis; burden of harm estimated at 9.2 million years of life lost to disability and death worldwide |
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Diagnostic errors |
Occur in 5% of adults in outpatient settings; around 50% have potential to cause significant harm |
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Unsafe transfusion practices |
Expose patients to risk of adverse reactions and infection |
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Radiation errors |
Overexposure to radiation or wrong-patient or wrong-site identification. |
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Lack of recognition of sepsis |
Sepsis affects around 31 million people with 5 million deaths per year worldwide |
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Venous thromboembolism (VTE) prevention |
VTE accounts for 1/3rd of the complications attributed to hospitalisation |
Table 1: common patient safety issues and impacts (1)
Most medical adverse events are not the result of a single action or event. Reason described a theory of active and latent failures, proposing that accidents within most complex systems including healthcare systems, are caused by a breakdown or absence of safety barriers across 4 levels (3). He describes these as organisational influences, supervisory factors, preconditions for unsafe acts (latent failures) and unsafe acts (active failures) (3). Some examples are shown below.
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Organisation culture, values and beliefs, willingness of an organisation to openly learn and communicate |
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Organisational influences |
Organisational processes – strategic planning, policies, procedures, corporate oversight |
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Resource management – support from senior leadership to accomplish and support the above, allocation of human, equipment and monetary resources |
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Oversight and management of personnel and resources Training, guidance and engagement |
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Supervisory factors |
Planned operations – management and assignment of work, risk management, work tempo, scheduling |
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Failure to correct a known problem – when deficiencies in the team, individuals, equipment or environmental hazards are known to the supervisor but allowed to continue |
This model is also referred to as the ‘Swiss cheese model’ – with the holes in the cheese depicting the failure or absence of safety barriers within a system (3). Most patient harm events are associated with multiple active and latent failures, although not every hole in a system will lead to an adverse event (3). An example could be a prescribing error – a doctor is prescribing medication in the middle of a busy ward. The active failure and unsafe act is a perceptual error – they are overloaded by noise and distraction and are unable to concentrate. The latent failures may involve preconditions for unsafe acts, including environmental factors (noise and distraction), task complexity and any number of team or individual factors, supervisory factors including training, risk management and failure to correct known problems, and organisational influences, including monetary resources to provide staff with enough computers and office space, cultural values and support from senior leadership. The risk of an error occurring is higher when these factors all come together (3).
Medical errors can also be grouped into errors of omission – for example not strapping a patient into a chair – or errors of commission, where the wrong action is taken, for example administering the wrong medication (4).
Other terminology often used includes:
HUMAN FACTORS
Human factors (HF) concerns the factors affecting our own performance and how we interact with others, teams and technology. Fatigue is a key factor, well recognised by the aviation industry, with strict limits on pilots’ hours. Fatigue affects decision making, situational analysis and awareness. Pausing to confirm a clinical decision can be key in preventing an error (5). Hydration, nutrition and recovery are important. A 1 -2 kg loss of body water through perspiration which is not replaced by drinking can cause a 15-20% reduction in cognitive function (5). Healthcare professionals’ environments may make a balanced diet difficult, with only 12% of surveyed UK NHS staff feeling that the NHS supported this due to a lack of health food options in the workplace (5). Healthcare professionals often skip breaks – preplanning short breaks into clinics or operating lists can be a solution. Emotions and stress also impact.
Communication and team work is key; verbalising instructions and using closed-loop communication can help (5).
WHAT CAN WE DO?
As healthcare professionals, we can critically examine the environments we work in. Are there organisational factors that we can influence, is there a known problem within the environment that is being ignored, what is our working environment like, should we lobby for a prescribing corner, is there a habitual ‘bending of the rules’ that can be addressed? Are medications with similar names stored next to each other?
We can learn from errors that do occur, and from near misses. Near misses should be given as much attention as adverse events. Healthcare systems will have their own ways of examining errors, such as ‘datix’ or ‘incident report’ systems. These can be completed by any member of the healthcare team. A root cause analysis (RCA) is an investigative tool used to understand why an incident has occurred, and will be applied to incidents as needed. There are a number of different templates you can use (6). Models for change such as the Plan, Do, Study, Act (PDSA) cycle can be used (7).
We can be aware of and address human factors that influence our own performance and our ability to work with others (5). A team brief at the start of the day and a debrief at the end can bring the team together. The anacronym HALT is useful – stop if possible if Hungry, Angry, Late (or lonely) or Tired (5). Tools such as SBAR (Situation, Background, Assessment and Recommendation) can be used to streamline communication at key points in the day like handovers (7).
We all have a responsibility to take action to improve patient safety. The Institute for Healthcare Improvement (IHI) has lots of useful resources available this Patient Safety Awareness Week (7).
About the author:
SIAN COPLEY
Young EAP Representative for Advocacy
United Kingdom
Sian is a member of the Royal College of Paediatrics and Child Health (RCPCH) Trainees’ Committee and currently works as a third-year resident at the Health Education North East in the UK. In her new role, she looks forward to representing trainees’ views on issues related to child health across Europe, raise awareness of current issues and promote this within paediatric training, as well as to advocate for children’s rights to health.
References
New ways to test high-risk medical devices.
Manufacturers of medical devices need to test their products before being allowed to market them. Specifically, they require clinical data showing their medical device is safe and efficient. In this context, the EU-funded CORE-MD project will translate expert scientific and clinical evidence on study designs for evaluating high-risk medical devices into advice for EU regulators. The project will propose how new trial designs can contribute and suggest ways to aggregate real-world data from medical device registries.
It will also conduct multidisciplinary workshops to propose a hierarchy of levels of evidence from clinical investigations, as well as educational and training objectives for all stakeholders, to build expertise in regulatory science in Europe. CORE–MD will translate expert scientific and clinical evidence on study designs for evaluating high-risk medical devices into advice for EU regulators, to achieve an appropriate balance between innovation, safety, and effectiveness. A unique collaboration between medical associations, regulatory agencies, notified bodies, academic institutions, patients’ groups, and health technology assessment agencies, will systematically review methodologies for the clinical investigation of high-risk medical devices, recommend how new trial designs can contribute, and advise on methods for aggregating real-world data from medical device registries with experience from clinical practice The consortium is led by the European Society of Cardiology and the European Federation of National Associations of Orthopaedics and Traumatology, and involves all 33 specialist medical associations that are members of the Biomedical Alliance in Europe.
