Speak Up for Patient Safety

Whenever a doctor cannot do good, he must be kept from doing harm

- Hippocrates

What is patient safety?

It emphasizes safety in health care through the prevention, reduction, reporting, and analysis of error and other types of unnecessary harm that often lead to adverse patient events. The frequency and magnitude of avoidable adverse events, often known as patient safety incidents.

While health care has become more effective it has also become more complex, with greater use of new technologies, medicines and treatments. Health services treat older and sicker patients who often present with significant co-morbidities requiring more and more difficult decisions as to health care priorities. Increasing economic pressure on health systems often leads to overloaded health care environments.

What are the components of patient safety?

Patient safety is often assessed based on five outcomes of error, adverse events, infections, injuries, and mortality. These outcomes are the final measures used in patient safety to articulate the harms faced by patients. However, these outcomes are passive means of achieving patient safety.

Is there a framework for measuring patient safety?

In the 1960s, health services researcher Avedis Donabedian defined the "Donabedian triad," which is still widely used today, it defines 3 ways

1. Structures—how care is organized?
2. Processes—what is done to the patient?
3. Outcomes—what ultimately happens to the patient?

A structural measure of patient safety might assess whether a hospital has key resources in place to improve safety, such as an electronic health record or a mechanism to rapidly start the work of root cause analysis teams after a serious adverse event has occurred.?

Process measures assess adherence to safety standards, such as the proportion of surgical patients for whom a postoperative checklist is completed or the proportion of patients in a hospital receiving appropriate prophylaxis for venous thromboembolism.?

Outcome metrics can measure the incidence or prevalence of adverse events or harm experienced by patients as a result of interaction with the health care system.

The choice of measurement method also depends on the reason measurement is being performed. Measurement is used for a variety of purposes: to evaluate the effectiveness of safety interventions, identify new or emerging safety threats, compare safety across hospitals and clinics, or to determine whether patient safety is improving over time.?

There is no one-size-fits-all approach to measurement, the choice of metric varies depending on the purpose of measurement.

Why does patient harm occur?

A mature health system takes into account the increasing complexity in health care settings that make humans more prone to mistakes. For example, a patient in hospital might receive a wrong medication because of a mix-up that occurs due to similar packaging. In this case, the prescription passes through different levels of care starting with the doctor in the ward, then to the pharmacy for dispensing and finally to the nurse who administers the wrong medication to the patient.

Had there been safe guarding processes in place at the different levels, this error could have been quickly identified and corrected. In this situation, a lack of standard procedures for storage of medications that look alike, poor communication between the different providers, lack of verification before medication administration and lack of involvement of patients in their own care might all be underlying factors that led to the occurrence of errors.?

Traditionally, the individual provider who actively made the mistake (active error) would take the blame for such an incident occurring and might also be punished as a result. Unfortunately, this does not consider the factors in the system previously described that led to the occurrence of error (latent errors). It is when multiple latent errors align that an active error reaches the patient.

To err is human, and expecting flawless performance from human beings working in complex, high-stress environments is unrealistic. Assuming that individual perfection is possible will not improve safety. Humans are guarded from making mistakes when placed in an error-proof environment where the systems, tasks and processes they work in are well designed.?

Therefore, focusing on the system that allows harm to occur is the beginning of improvement, and this can only occur in an open and transparent environment where a safety culture prevails. This is a culture where a high level of importance is placed on safety beliefs, values and attitudes and shared by most people within the workplace.

What is the the burden of patient harm?

Every year, millions of patients suffer injuries or die because of unsafe and poor-quality health care. Many medical practices and risks associated with health care are emerging as major challenges for patient safety and contribute significantly to the burden of harm due to unsafe care.?

Some of the patient safety situations causing most concern are described here:

• Medication errors are a leading cause of injury and avoidable harm in health care systems: globally, the cost associated with medication errors has been estimated at US$ 42 billion annually.
• Health care-associated infections occur in 7 and 10 out of every 100 hospitalized patients in high-income countries and low- and middle-income countries respectively .
• Unsafe surgical care procedures cause complications in up to 25% of patients. Almost 7 million surgical patients suffer significant complications annually, 1 million of whom die during or immediately following surgery.
• Unsafe injections practices in health care settings can transmit infections, including HIV and hepatitis B and C, and pose direct danger to patients and health care workers; they account for a burden of harm estimated at 9.2 million years of life lost to disability and death worldwide (known as Disability Adjusted Life Years (DALYs)).
• Diagnostic errors occur in about 5% of adults in outpatient care settings, more than half of which have the potential to cause severe harm. Most people will suffer a diagnostic error in their lifetime.
• Unsafe transfusion practices expose patients to the risk of adverse transfusion reactions and the transmission of infections. Data on adverse transfusion reactions from a group of 21 countries show an average incidence of 8.7 serious reactions per 100 000 distributed blood components.
• Radiation errors involve overexposure to radiation and cases of wrong-patient and wrong-site identification. A review of 30 years of published data on safety in radiotherapy estimates that the overall incidence of errors is around 15 per 10 000 treatment courses.
• Sepsis is frequently not diagnosed early enough to save a patient’s life. Because these infections are often resistant to antibiotics, they can rapidly lead to deteriorating clinical conditions, affecting an estimated 31 million people worldwide and causing over 5 million deaths per year.
• Venous thromboembolism (blood clots) is one of the most common and preventable causes of patient harm, contributing to one third of the complications attributed to hospitalization. Annually, there are an estimated 3.9 million cases in high-income countries and 6 million cases in low- and middle-income countries.

Key Facts:-

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. The harm can be caused by a range of adverse events, with nearly 50% of them being preventable.
2. Each year, 134 million adverse events occur in hospitals in low- and middle-income countries (LMICs), due to unsafe care, resulting in 2.6 million deaths.
3. Another study has estimated that around two-thirds of all adverse events resulting from unsafe care, and the years lost to disability and death (known as disability adjusted life years, or DALYs) occur in LMICs.
4. Globally, as many as 4 in 10 patients are harmed in primary and outpatient health care. Up to 80% of harm is preventable. The most detrimental errors are related to diagnosis, prescription and the use of medicines.
5. In OECD countries, 15% of total hospital activity and expenditure is a direct result of adverse events.
6. Investments in reducing patient harm can lead to significant financial savings, and more importantly better patient outcomes. An example of prevention is engaging patients, if done well, it can reduce the burden of harm by up to 15%.

Speak up for patient safety

The health care in modern era is considered as a service where the outcomes are coproduced by the interaction of the patients & families with the healthcare systems through their journey of seeking health. Patients are central to any healthcare system around the world as quality of services delivered to them translates to the mere structures & processes that derive their health outcomes.

A?well-coordinated,?timely and?measurable?national patient?safety?initiative which?engages?all?the?levels of?care?continuum?across?a patient’s journey?in?the?health?system?through?a multipronged approach is required.?

The goals of such initiative should?be?reviewed and renewed annually?and?progress must be shared transparently?with?the?most important?consumer?of?the?healthcare?systems,?the patient?themselves.?

Patient?safety and quality of care?are essential for delivering?effective health services and?achieving universal health coverage.?Investment in improving patient?safety?can lead to signi?cant??nancial?savings as the cost of prevention is much lower than the?cost?of treatment due to harm. Greater patient involvement and engagement is the key to safer care which can reduce the burden of preventable harm by up to 15%, saving billions of dollars each year as per World Health Organization. Patient safety is everyone’s business and no professional in the healthcare ?eld have an intention to harm their patients.

One factor that allows preventable harm to reach the patients is not speaking up when seeing or coming across a patient safety concern?in?a?healthcare?setting.?Speaking?up?for?patient safety?requires?courage?and?deliberation?in?addition?to?sound implementation of?a?‘just?culture’ and?principles?of?psychological?safety.??

In essence,?it is?the patient?safety?culture that promotes partnership with patients, encourages?reporting?and?learning?from errors, and creates a?blame-free?environment where health workers are empowered and trained to reduce errors.?

Speaking up for patient safety can take various forms:

• An activated patient questioning?the?need?for?a?test.
• A?junior?medical?student speaking?up?in operation?theater?as?soon?as a breach in?sterile??eld is?observed.
• A?nurse ?agging a?medication?contraindication?or?management o?cer?bringing below benchmark data to a healthcare leader’s attention.

Speaking up for patient safety emphasizes why using the power of voice and observations is essential to patient?safety?improvement around the world.

How is technology helping in improving patient safety?

Technology has become an integral part of medicine today. The right technology can assist with increased efficiency, improved quality, and reduced costs. Some of the many advantages technology can provide include:

1. Communication Between Clinicians — Often in a patient’s medical journey, multiple healthcare professionals are involved in their care. This can dramatically increase the potential for miscommunication or error. Communication failures are one of the most common factors that contribute to the occurrence of adverse events.

2.Reduces Medication Error — Prescribing errors are another common medical error that can potentially lead to serious complications. Electronic prescribing can help reduce prescription errors by allowing clinicians to send prescriptions electronically to the pharmacy. Medical alerts, clinical flags, and reminders are also ways technology can help reduce medication errors and improve patient safety.

3.Provides Access To Information — Many serious medication errors are the result of clinicians not having sufficient information about the patient or drug. Information technology has drastically improved the access to reference information.

4.Increases Patient-Centered Care — Encouraging patients to be more involved in their care is important for many reasons including increased compliance and patient satisfaction. Technology helps contribute to patient-centered care by fostering communication between providers and patients via online portals, text messaging, video calls. It also increases access to information such as online medical records, which can improve self-monitoring and patient convenience.

Health Saarthi is one such digital technology platform which aims to assist with patient safety.?

Visit www.healthsaarthi.com

Download the HS Buddy App from Google Play store

Health Saarthi provides H Locker, an online digital health locker for uploading, storage, sharing & retrieval of health records in a secure & safe environment.

Health Saarthi via its Live E-Prescription, assists the physician/ doctor to generate prescriptions digitally & share the same with the required stakeholders like pharmacies, patient directly via the H Locker without using emails along with medication alerts to help patients comply with their prescribed medications.

Access to health, medicine, healthcare is made simple by Health Saarthi by providing relevant, authentic information via defined modes, ie- audio, video, BLOGS, Articles etc through the HS Knowledge Bank.

Health Saarthi encourages patient-provider relationships by providing tele consultancy, messaging alerts, reminders to improve self monitoring & convenience.

With inputs from: https://psnet.ahrq.gov/?|?https://www.who.int/ | https://www.researchgate.net/?

Disclaimer: This information should not be construed as a medical advice. Reader discretion is recommended.