WHO shines spotlight on patient safety

The WHO is aiming to reduce medication errors by half over the next five years

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Five years ago, health systems analyst Professor Jeffrey Braithwaite told an Australian audience that despite decades of attempts to improve the healthcare system, patients continued to receive care that was highly variable, frequently inappropriate, and too often, unsafe.

Sadly, Professor Braithwaite, director of the Australian Institute of Health Innovation, had no more optimistic story to tell at a recent patient safety seminar at Sydney’s Sax Institute.

While more data is available on hospital care, with one in 10 admissions associated with some error, less is actually known about medical errors in primary care.

But we did know that only about half of all care given in Australia was in line with guidelines and level 1 evidence, Professor Braithwaite said. And that 30% of healthcare encounters involved waste, unnecessary care or overuse.

In the US, medication errors cause 1.3 million injuries every year, and one death per day. The global cost of such errors, according to the WHO, is an estimated $US42 billion a year, or almost 1% of total health expenditure.

“We all expect to be helped, not harmed, when we take medication,” WHO Director-General Dr Margaret Chan said in a statement.

“Apart from the human cost, medication errors place an enormous and unnecessary strain on health budgets,” Dr Chan said. “Preventing errors saves money and saves lives.”

New challenge

Now the WHO has launched the Global Patient Safety Challenge to cut medication harms in half over the next five years. Following the WHO’s “Clean Care is Safe Care” challenge on hand hygiene in 2005, and the Safe Surgery Saves Lives challenge in 2008, this latest initiative will be aimed not only at healthcare professionals, but also patients and the public.

Specifically, strategies will be focussed on factors that individually or in combination could affect the medication a patient receives, and put them at risk of severe harm, disability or death.

These factors include health worker fatigue, overcrowding, staff shortages, poor training and patients receiving incorrect information.

Professor Sir Liam Donaldson, WHO envoy for patient safety and former chief medical officer for England, told the seminar that paternalistic and hierarchical attitudes in healthcare were dangerous, and had to be eliminated.

Instead of patients being cast in the role of the passive recipient of healthcare, they needed to be empowered to manage their conditions, to ask for a second opinion and to be informed about the care they received, he said.

Hierarchical attitudes in the aviation industry had been responsible for planes coming down because co-pilots were afraid to challenge the captain, he noted.

But while the aviation industry had put specific measures in place and fundamentally eliminated its hierarchical culture, Professor Donaldson said hierarchies were alive and well in medicine.

Taking a leaf out of the book of the oil, aviation and rail industries and strengthening the systems clinicians worked under, could make it almost impossible for mistakes to occur.

Another major cause of medication error was abbreviations in hospital records, he said.

In his years of poring over patient adverse-events reports, Professor Donaldson said abbreviations stuck out as a dangerous, but easily changeable habit.

People had died from one clinician misreading another’s handwritten “1000U” for 1000 units as 10,000, he said.

Outside of these structural changes, the WHO challenge also aimed to improve each stage of the medication process where errors could occur, including prescribing, dispensing, administering, monitoring and use.

Don’t add to bureaucracy

It was well known that most medication errors did not occur because of malicious healthcare workers, but were instead genuine mistakes, Professor Donaldson said. Yet he cautioned against more regulation.

For example, if a nurse gave a patient the wrong medication after mistaking it for a bottle with a similar label and colour, the problem should be remedied by working with the manufacturers to change the bottle rather than instituting more rules in the hospital.

Writing in a 2015 article on resilient healthcare, Professor Braithwaite said that increasingly constricting regulation regimes had “trapped patient safety in a ‘more of the same, more intensively’ mantra”. But increasing attempts at standardisation and root cause analyses had been ineffective and cumbersome, he said.¹

“The burden of these falls on clinicians on the front line already facing an extremely busy working environment in clinics, wards, operating theatres and family practices.

“Work as-imagined cannot capture how circumstances vary, the diversity of patients, how goal conflicts abound, how expected resources may be missing,” he said. The complexity of healthcare added to the difficulty of adherence to guidelines reaching 100%.

In contrast to aviation, healthcare has a tradition of autonomous practice, and patient preference would always mean that guidelines might not be followed at all times.

“The complexity of healthcare is not amenable to quick fixes,” Professor Braithwaite said.

Nevertheless, we should also be recognising the “astonishing” fact that things go right 90% of the time, Professor Braithwaite said. And the best kind of patient safety management would focus on how good clinical care could be improved rather than trying to prevent failures.

In general practice, one of the commonest errors occurs related to following up test results.

Some practices used a “no news is good news” approach to informing patients of their test results, and patients were told to assume the test was normal if they didn’t hear back about a test result, Professor Donaldson said.

This was a key area of vulnerability, with patients commonly missing out on necessary follow-up because test results had somehow been lost in the system.

Best practice was for patients to be notified of all test results, whether it was by a phone call, email or even an app.

Barriers to safety

One major area of concern in relation to patient safety was that errors resulting in little or no harm tended to be ignored by the healthcare system, Professor Donaldson said.

“In patient safety, we tend to concentrate on death, but some errors are potentially life changing,” he said.

Such errors accounted for millions of cases in the UK each year, yet research had shown resilient organisations took a “strong response to a weak signal of failure”, Professor Donaldson said. Low-harm errors were a weak signal that something was going wrong in the system, and gave people an opportunity to improve the system before actual harm occurred.

Furthermore, attempts to improve safety in hospitals and healthcare systems was not helped by research in this space often being stymied by a lack of resources, Professor Braithwaite said.

Professor Braithwaite told of an investigation he was currently undertaking into the running of hospitals and its impact on patient outcomes had been held up by years of navigating ethics approval.

Reference 

1. https://www.ncbi.nlm.nih.gov/pubmed/26294709