Medical errors have always been a major challenge within the healthcare sector not only in Nigeria, but the world over. It occurs at all levels of care and at almost every point of care as you make your journey through the typical visit to a clinic, medical center or hospital.
It may range from errors in patient identification, ineffective communication resulting in patient harms, medication errors either in prescription, dispensing, administering or even monitoring its effects. Others can be surgical in nature, nosocomial (hospital acquired) infections and some occurring as patient harm resulting from patient falls.
These errors can lead to various degrees of patient harms and sometimes, yes, even death.
However, the degree of harm resulting from medical errors, the burden on the patient and their relatives, including the healthcare team, are enormous with far reaching consequences on the economy, cost of care, psychological (patient and healthcare worker alike) and trust of healthcare systems.
Recently there has been huge condemnation of the quality of healthcare service in the country, sometimes perceived as a direct result of incompetence or negligence on the part of the healthcare practitioner and at some other times seen as a result of system failure resulting from poor investments in healthcare infrastructure, poor training facilities and the lack of required equipment or technology that is consistent with what is obtainable offshore.
Whichever your opinion, it is clear to all that the current level of healthcare delivery has to improve at all levels of care and especially the incidence of medical errors.
Why Do Errors Occur?
A two-month old baby was admitted into the peadiatric unit on account of profuse vomiting and diarrhea. In the course of her care, it was noticed that an improvised tourniquet has been left in place for longer than required and has resulted in strangulation injury of the limb that necessitated amputation of the affected limb.
A 45-year-old banker had checked in for hemorrhoidectomy, but suffers massive brain injury following failure of Anaestesia and has remained in vegetative state for the rest of his life.
A patient in the course of treatment in a hospital was given parenteral morphine. The patient was sensitive to the drug and developed respiratory depression. The patient’s doctor called in an order for an ampoule of Naloxone to be administered.
A dose of a different medication was administered but there was no response, a second dose was administered and again the patient showed no improvement. The patient subsequently died.
An inquest into the death revealed that the nurse had administered LANOXIN instead of NALOXONE. These horrific cases make the headlines, but are only a tip of the iceberg.
The Thursday Morning Meeting
The Thursday Meeting is a gathering that brings the entire medical team together to discuss and deliberate on a number of clinical issues, including difficult cases, unexplained patient deaths and prolonged patient hospital stay.
The Morbidity and Mortality Meeting, as it called, is held every Thursday morning as a mode of clinical education and a way of reviewing and improving practice.
The morbidity and mortality (MMR) review traditionally exists in healthcare organizations and takes place in the context of wider clinical governance and management structures. MMR describes a systematic approach that provides members of a healthcare team with the opportunity for peer review of adverse events, complications of mortality to reflect, learn and improve patient care.
The MMR meeting is a unique opportunity for caregivers to improve quality of care offered through case studies. They provide clinicians and members of the healthcare team with a routine forum for open examination of adverse events, complications and errors that may have led to illness or death in patients.
Thursday’s meetings support a systematic approach to the review of patient deaths or care complications to improve patient care and provide professional learning. The meetings give ownership to clinical teams and offer a direct opportunity to improve care delivery in a timely manner.
These meetings X-ray the details of the contributory factors that affect patient care outcomes.
Attending these meetings made me realize the sad fact that healthcare can actually harm the people that it should be helping. This is true and alarming.
However, healthcare is a complex process, and it is not surprising that patient safety can be threatened and healthcare is not as safe as it should be, not even in the highest level of care, tertiary hospitals, the reason being not only the human factors but also factors that include systems, processes, regulatory and legislatives.
Patient safety concerns of many kinds occur during the course of providing healthcare and include wrong-site surgeries, surgical injuries and foreign bodies post-surgery; transfusion errors, medication errors and so on. Reduction of patient safety problems will mean understanding the dimensions that influence quality care.
I have come to understand that patient safety issues are multifaceted and a lot of factors play major roles in determining whether care is safe or otherwise – I share some of my insights below:
Patient safety is a major concern for all healthcare providers. It appears perverse that patients can suffer harm when they are being treated and cared for. However, healthcare is complex and its outcome is influenced by many factors. It is inevitable that within any healthcare system patients will be harmed, and in every encounter, there is the potential for harm to occur. This has been recognized since the time of the physicians of Ancient Greece and Rome. The experience has been similar in other countries.
In the United States, the full magnitude and impact of errors in health care was not appreciated until the 1990s.
In 1999, the Institute of Medicine (IOM) of the National Academy of Sciences released a report: To Err is Human: Building a Safer Health System, revealed a staggering statistic: between 44,000 and 98,000 preventable deaths occur annually due to medical error in hospitals, 7,000 preventable deaths related to medication errors alone.
In 2004, the Canadian Adverse Events Study found that adverse events occurred in more than 7% of hospital admissions, and estimated that 9,000 to 24,000 Canadians die annually after an avoidable medical error.
The Department of Health Expert Group in June 2000 estimated that over 850,000 incidents harm National Health Service hospital patients in the United Kingdom each year. On average forty incidents a year contributes to patient deaths in each NHS institution.
The real problem isn’t how to stop bad doctors from harming, even killing their patients. It’s how to prevent good doctors from doing so.
The past few years has seen an increasing focus on the issue of errors in medicine. In particular, errors made by doctors, nurses and para-medical staff in hospitals have received significant attention.
“Human factors” can be defined as the study of the interrelationships between humans, the tools we use and the environment in which we live and work. It focuses on the cognitive and physical abilities of people as they interact with technology. This is an interdisciplinary field, drawing on knowledge from industrial and software engineering, psychology, ergonomics, design and management.
The causes of human error include: fatigue, workload, limitations of human cognitive processes, poor interpersonal communications, flawed decision-making processes, leadership problems and team work issues. Others include variations in healthcare provider training & experience, depression and burnout, diverse patients, unfamiliar settings, time pressures, failure to acknowledge the prevalence and seriousness of medical errors and increasing working hours of medical staff.
Expecting flawless performance from humans working in complex, high stress environment may be unrealistic and a mature health system takes account of the increasing complexities in the healthcare setting that makes the risk of error high. For example, a healthcare system that ensures proper training, licensure and privileges of its healthcare team.
Until recently, the commonest approach to looking at patient safety has been to focus on the errors and violations of the individual healthcare worker. This has now changed to a systems approach, which sees causal factors as part of the system as a whole. However, the individual healthcare worker is a crucial factor in the provision of safe care, and it is important that this aspect is not ignored.
Some individual factors that impact on safety, such as inexperience or distractions, will apply to all healthcare workers at some point in their careers and so require organizational polices to address them. Other factors will be true for some individuals but not others, and these involve psychological or physical health problems.
Setting and enforcing standards for safety through regulatory and related mechanisms such as licensing, certification, privileging, and accreditation and define minimum performance levels for healthcare professionals and organizations. Additionally, the process of developing and adopting standards helps to form expectations for safety among providers and consumers.
A system can be defined as a collection of components and the relations between them.
In health care there are human components (staff and patients), hardware components (computers, monitors, paper records, buildings, beds, drugs), management components (policies and procedures) and financial components (financial decisions and budgets). A systems approach to errors involves looking for sources of error generation inherent in the systems within which humans work. This can include, for example, looking at: the design of equipment, the way in which the work is structured, procedural aspects, information availability and communication networks within organizations. Even though humans may be acting with good intentions, and be skilled and experienced in their particular work, problems within systems can “call forth” error behaviour in these workers.
A misunderstanding of taking a systems approach to errors is that it absolves the individual of any responsibility. This is absolutely incorrect.
Doctors and other healthcare professionals obviously have to uphold the expected highest standards of performance, and have an obligation to participate in continuing education to ensure their skills and knowledge is up to date. A systems approach to safety does not mean staff can simply deny responsibility and “blame the system”. On the other hand, it does mean that when errors occur, the “big picture” must be examined.
Some care settings or care situations are particularly prone to hazards, errors and system failures. For example, in intensive care units (ICUs), patients are vulnerable, their care is complex and involves multiple disciplines and varied sources of information, and numerous activities are performed in patient care; all of these factors contribute to increasing the likelihood and impact of medical errors. A study of medical errors in a medical ICU and a coronary care unit shows that about 20% of the patients admitted in the units experienced an adverse event and 45% of the adverse events were preventable (Rothschild, et al., 2005).
The most common errors involved in preventable adverse events were: diagnostic errors, medication errors, and preventable nosocomial infections. Various work system factors are related to patient safety problems in ICUs, such as not having daily rounds by an ICU physician. Another example, a patient might receive the 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, then to the pharmacy for dispensing, and finally to the nurse who administers the wrong medication to the patient. In this case the lack of standard procedure for storage of medications that look alike, poor communication between different providers, lack of verification before medication administration, and lack of involvement of patients in their care.
Teamwork And Communication
During complex situations, communication between health professionals must be at its best. There are several techniques, tools, and strategies used to improve communication. Communication between healthcare professionals not only helps achieve the best results for the patient but also prevents any unseen incidents.
The Joint Commission’s Annual Report on Quality and Safety 2007 found that inadequate communication between healthcare providers, or between providers and the patient and family members, was the root cause of over half the serious adverse events in accredited hospitals.
SBAR is a structured system designed to help team members communicate about the patient in the most convenient form possible.
Practice Consistent With Current Medical Knowledge
Evidence based practice has since been advocated by our leaders in healthcare. Evidence-based medicine integrates an individual doctor’s examination and diagnostic skills for a specific patient, with the best available evidence from medical research. The doctor’s expertise includes both diagnostic skills and consideration of individual patients’ rights and preferences in making decisions about his or her care. The clinician uses pertinent clinical research on the accuracy of diagnostic tests and the efficacy and safety of therapy, rehabilitation, and prevention to develop an individual plan of care. The development of evidence-based recommendations for specific medical conditions, termed clinical practice guidelines or “best practices”, has accelerated in the past few years.
Healthcare providers and practitioners should from time to time, improve on their clinical knowledge and skill to keep updated on new diagnostic criteria, treatment protocols and medications. The healthcare regulatory system should provide guideline that will unify practice backed by evidence and current standard global practices customized for our use.
Health literacy is a common and serious safety concern. A study of 2,600 patients at two hospitals determined that between 26-60% of patients could not understand medication directions, a standard informed consent, or basic health care materials. This mismatch between a clinician’s level of communication and a patient’s ability to understand can lead to medication errors and adverse outcomes.
The Institute of Medicine (2004) report found low health literacy levels negatively affects healthcare outcomes. In particular, these patients have a higher risk of hospitalization and longer hospital stays, are less likely to comply with treatment, are more likely to make errors with medication, and are more ill when they seek medical care.
It therefore implies that care should be customized to the need of the patient. Patient and caregiver interaction are a cornerstone of a satisfied patient and significantly contributes to whatever the outcome may be. Patient engagement and communicating effectively determines whether we have a happy and satisfied patient or a dissatisfied and aggrieved patient.
Traditionally, health care has taken what has been called the “person approach” to errors, with an emphasis on “naming, blaming and shaming” the individual seen as responsible for the error. As noted earlier, with this approach errors and unsafe acts have been viewed as reflecting carelessness, inattention, negligence, forgetfulness or poor motivation.
Focusing on individuals as being the causes of errors means the “big picture” is lost.
Setting performance standards and expectations for safety, highlights the need for explicit and consistent standards for patient safety. Such standards not only define minimum expected levels of performance, but also set expectations for providers, health maintenance organizations (HMOs) as purchasers of healthcare and consumers. The roles of licensing and accrediting bodies also play important roles relative to standards for healthcare organizations, professionals, drugs and medical devices and this is same for HMOs as purchasers of healthcare and professional groups in setting expectations are also very important.
Healthcare organizations must develop a culture of safety such that an organization’s care processes and workforce are focused on improving the reliability and safety of care for patients. Safety should be an explicit organizational goal that is demonstrated by the strong direction and involvement of governance, management, and clinical leadership. In addition, a meaningful patient safety program should include defined program objectives, personnel, and budget and should be monitored by regular progress reports to governance
The growing awareness and concerns of healthcare errors creates an imperative to improve or understand the problem and device workable solutions.
For some errors, the knowledge of how to prevent them exists already, while for some others additional work is needed to develop and apply the knowledge that can improve patient care.