Making health care safer and better...
Acknowledgements to the World Health Organisation, Technical paper Regional strategy for enhancing patient safety (EM/RC52/4) for some of the information below.
Improving the safety of patient care
Patient safety in the hospital environment has become a global and regional issue of immense importance in both first and third world contexts. About 50% of healthcare errors are considered preventable and with an estimated average of 10% of all in-patient visits resulting in some form of unintended harm, the need to tackle patient safety is clear.1 The increasingly complex interaction between humans and healthcare systems has led to an inevitable risk to patients in the delivery of healthcare services.2
For the latest information on Patient Safety worldwide, click onto the World Health Organisation Patient Safety website. You will find this at: www.who.int/patientsafety/en/
Culture of denial
Patient safety is being challenged not only by the complexity of care processes but also, first by a culture of denial and blame - where these two characteristics have predominated over an environment of problem-solving and learning and second, by an inconsistent reporting and learning system that has prevented the collection and dissemination of information in any meaningful way.
On October 12, 1999, Dr. Lucian Leape, a professor at the Harvard School of Public Health, gained the attention of a US Congressional subcommittee when he briefed them on the state of human error management in the US medical industry.3 The numbers were staggering: an estimated one million people injured by errors in treatment at hospitals each year in the United States, with an estimated 120,000 deaths arising from those errors.4 This number was three times greater than those who died in car accidents and 1000 times greater than those who died in commercial aircraft accidents. These errors were accompanied by an estimated $33-billion price tag.5
Dr. Leape further reported that only 2 to 3% of major errors are reported through hospital incident reporting systems and that healthcare workers often report only what they cannot conceal.6
1. Information from Technical Paper - Regional Strategy for Enhancing Patient Safety (Regional Committee for the Eastern Mediterranean Region) September 2005, World Health Organisation.
3. Testimony, United States Congress, House Committee on Veterans' Affairs, Dr Lucian L Leape, MD October 12, 1997.
4. The later released Institute of Medicine report put the number of deaths at between 44 000 and 98 000 deaths in the US each year.
5. Patient Safety and the "Just Culture" - a Primer for Health Care Executives Medical Event Reporting System - Transfusion Medicine (MERS-TM) prepared by David Marx for Columbia University under a grant provided by the National Heart, Lung and Blood Institute.
In May 2002, the World Health Assembly passed resolution WHA55.18, which urged countries to pay the greatest possible attention to patient safety and requested the Director-General of WHO to carry out a series of actions to promote patient safety. The Resolution outlines the various responsibilities of WHO in providing technical support to Member States in developing reporting systems, reducing risk, formulating evidence-based policies, fostering a culture of safety and encouraging a research agenda on patient safety. The resolution ensured that the drive for safer health care has become a worldwide endeavour.
Greater challenges in resource-poor settings
In resource-poor settings the challenges are even greater than in developed countries. Developing countries have less funding for recurrent maintenance, insufficient infrastructural resources and outdated systems that are not regularly reviewed.
The overall costs of adverse events can be considerable. Loss of confidence within clinical teams and loss of reputation and credibility of services and facilities are just some of the ramifications of adverse events. As well as causing avoidable human suffering, the financial and opportunity costs to health services are estimated at between 5% and 10% of health expenditure.
The first meeting of the WHO Global Research Programme for Patient Safety, under the auspices of the WHO World Alliance for Patient Safety, was held in Washington DC in November 2005. This, in turn, led to the formation of the World Alliance Research Council to develop a Patient Safety Research Agenda, which met in Washington DC in April 2006. At this meeting agreement was reached on fundamental concepts: that preventable patient harm is unacceptable at any time and that harm to patients is associated with poor clinical outcomes, is a waste of valuable resources, and leads to human rights issues and public health problems. It was agreed that more knowledge on adverse events in the different WHO regions was required.
In 2005, a Patient Safety Measurement Project under the auspices of the WHO commenced in nine African Countries in the Eastern Mediterranean and Africa WHO regions. Participating countries include Egypt, Tunisia, Morocco, Sudan, Yemen, Kuwait, Jordan, Kenya and South Africa. The first workshop took place in December 2005 in Cairo; the second in May 2006. Intensive training in using the retrospective patient record system was provided to the project members by the expert group as part of a "train the trainers" strategy.
In South Africa
Since it was introduced to the Free State Province in 2008, healthcare staff have reported over 6000 incidents using the AIMS system. The programme began as a pilot research project in 24 public sector hospitals and is now being rolled out in 45 institutions – 31 hospitals, nine Community Health Centres and five emergency medical service units. Since there are few developed mechanisms in South Africa to measure or address adverse events in the provincial health services, which serve 80% of the country's population, this project seeks to introduce an incident monitoring and improvement programme with the ultimate aim of reducing the incidence and severity of adverse events.
At the request of the Provincial Department of Health in the Free State, COHSASA AIMS Co-ordinator, Petro de Beer, has recently trained health staff, particularly clinical managers, from hospitals all over the Free State, on how to conduct root cause analysis. A total of 37 district managers, hospital CEOs, matrons and quality assurance staff members were given training (presentations and discussion) in two full day teaching sessions.
COHSASA posters encourage hospital staff in South Africa
to report adverse events and near misses to its call centre.
HOW DOES AIMS WORK?
The AIMS taxonomy includes 18 categories, or Healthcare Incident Types (HITs), and five supplementary specialty data sets to capture detail about the full spectrum of clinical and non-clinical adverse events and near misses that occur in the delivery of care. Each HIT includes a series of context specific, cascading natural language questions (up to nine levels) to generate a structured dataset describing the incident. It takes 7 minutes for a call centre operator to collect all relevant data for the incident.
The AIMS programme is currently being used in 31 public sector hospitals, nine CHC's and six EMS services in the Free State. Given the positive response to this programme in this province, it is hoped that a large-scale patient safety programme will eventually be developed and implemented across South Africa. It is expected that AIMS will become a valuable tool to help improve levels of patient safety and that lessons learnt will offer opportunities for more research and solutions in the wider sub-Saharan region.
Advantages in using a call centre to record incidents:
- Single Point of Entry for all departments'
- A phone call is all that is needed,
- Staff are guided through a series of simple questions that take 7 to 10 minutes to capture detailed data specific to the incident,
- Reporting facilities do not have to acquire and maintain computer systems, software, nor staff to run them
- Incidents are immediately available,
- The hospital staff have direct access to the database.
Potential of the incident monitoring approach to identify risk and reduce morbidity and mortality:
- With little effort staff are trained to report Incidents of different types and severity from a wide range of services,
- Calls take on average 5 to 7 minutes and staff feel comfortable reporting,
- Many incidents with potential to cause serious harm, and which would not normally be reported, are picked up,
- Hospital staff feel in charge of the project because incidents were reported directly to them to manage,
- Hospital staff gain in-depth understanding of workings of the hospital they had previously only perceived, but are now confirmed,
- As part of the reporting process staff learn about risk as the frequency of adverse events and near misses can be used as indicators of risk,
- Since staff report incidents themselves they will want to improve the situation,
- Learning from incidents can assist with:
- the development of additional barriers and preventive approaches,
- the refinement of standard to improve systems.