No room for mistakes in healthcare

MALAYSIA - DR Beatrice (not her real name) is no stranger to performing surgery and saving lives. At 40, this surgeon is also no stranger to patient safety and medical errors.

"Ninety-nine per cent of the time, everything is normal. But sometimes mistakes happen. We are human," she says.

She relates an experience when the 1% did occur, and she herself was involved. She says she was very sure all the gauze used during an operation had been removed and even had assurance from a colleague who had double-checked it with her.

But the patient developed slight complications hours later and was unable to swallow food.

It was determined after a repeat scope that a piece of gauze had been left in the patient's body and another procedure had to be done to remove it.

Fortunately, she says, the patient's family understood that doctors, too, are human and the case was settled amicably. The patient fully recovered.

Dr Beatrice admits that it is sometimes tough to bounce back after a mistake is committed. But "you let off steam somehow, get back to work and hope not to repeat the same thing".

She says errors in patient care do happen, including in prescribing the wrong medication or dosage.

"There was a time when a doctor had prescribed medication over the phone to a houseman and the dosage was 10 times more than what it was supposed to be," she relates, adding that the houseman followed orders and the nurses did not pick up on the mistake.

"The patient survived but it was a serious problem as she developed life-threatening side effects."

When patient safety is compromised, there are measures that must be taken, among them informing the patient and filing an incident report, which will then be handled by the hospital committee.

Mortality and morbidity meetings are also conducted on a regular basis at hospital and department level to highlight the mistakes made and methods to prevent similar cases from occurring, says Dr Beatrice.

Keeping patients safe

Patient safety has long been the subject of conversation with the World Health Organisation (WHO) deeming it a fundamental principle of healthcare.

WHO cautions that "every point in the process of care-giving contains a certain degree of inherent unsafety. Adverse events may result from problems in practice, products, procedures or systems."

It adds that patient safety improvements demand a complex system-wide effort, involving performance improvement, environmental safety and risk management, including infection control, safe use of medicines and safe clinical practice.

It also states that in developed countries, as many as one in 10 patients is harmed while receiving hospital care. In developing countries, the ratio could be higher.

The risk of healthcare associated infection in some developing countries is as much as 20 times higher than in developed countries, it adds.

WHO director-general Dr Margaret Chan has said before that unsafe injections worldwide are thought to cause around 1.3 million deaths, with economic losses of around US$535mil (RM1.7bil) in direct medical costs. This figure represents an astronomical loss of around 26 million years of life.

In Malaysia, the Health Ministry's medical care quality section, which is under the medical development division, and the Patient Safety Council of Malaysia say the future of patient safety is bright even though the "road is long".

"There are numerous issues that need to be addressed at the seven levels of patient safety', from external and organisational factors to work environment, teams, task and technology, individual staff as well as patient factors," they say.

There is a need to build a patient safety culture in healthcare facilities, promote patient safety movements, implement patient safety goals, encourage public and patient involvement, strengthen existing patient safety initiatives and increase the number of accredited hospitals, they emphasise.

While preventable adverse events do not occur often in hospitalised patients, among those that happen are medication error, infections and falls.

The two bodies add that the consensus on patient safety in this country is that it has improved due to better technology and practices as well as an increase in awareness due to various activities carried out by relevant parties.

Mahsa University College pro-chancellor and chairman Tan Sri Dr Ismail Merican, who is also former Health director-general, says there is a need to be aware of risks that may accompany healthcare delivery, and to learn how to recognise adverse events and medication errors and manage them.

"We need to practise a more open culture in which errors or service failures can be reported, analysed and remedial measures taken speedily," he says.

"There should be no finger-pointing. A no-blame culture is the best way to move forward, as often the systems are at fault, not the carers. We must work together as a team and institute proactive measures across all levels of healthcare."

Dr Ismail adds that it is also important to engage with patients and their carers. "Healthcare will never be risk-free. But we can drastically minimise risks if we can change human behaviour and make people more responsible in promoting patient safety and protecting our patients."

While not many will acknowledge their own errors "no matter how obvious", he says, a difference can be made by developing systems approach in prevention, analysis and learning from mistakes.

He says Mahsa, which hosted a two-day conference with the Health Ministry recently, incorporates patient safety in its nursing and medicine curriculum and also makes the topic a permanent agenda at events such as healthcare seminars, conferences and scientific meetings.

Patients no longer come in a "neat package" with diabetes or hypertension or bronchial asthma, he explains.

"Chances are he may have all three. So, unless you are a good, well-trained and competent internal medicine specialist or family medicine specialist or generalist, you will not be able to treat such patients optimally.

"Life is no longer easy for those who think they can rely entirely on CPGs (clinical practice guidelines) as CPGs can be quite impotent when it comes to dealing with patients with multi-faceted problems."

He warns that besides devastating consequences for patients and their families and causing distress to healthcare providers, medical mishaps can also undermine public confidence in the healthcare system.

It can also adversely affect aspects like the economy, settlement of clinical negligence claims and contaminated medical products.

The Health Ministry's medical care quality section and the Patient Safety Council of Malaysia say that a "just culture" of drawing the line between blameless and blameworthy actions is critical to the development of a learning culture.

"The intent is not to summarily punish a healthcare worker just because a patient suffered from harm while under his or her care. The factors contributing to the harm could be upstream factors' that are remote from the site where care was delivered. This is an important principle of patient safety," they explain.

They say the principle of "not blaming" but having a scientific investigation such as root cause analysis (RCA) that leads to correcting the conditions that contributed to the error or harm are vital in ensuring patient safety.

"Under a just culture' or non-punitive culture', one can learn from his mistakes (or the mistakes of others through a system of sharing) and improve patient safety by openly identifying and examining weaknesses in systems. In a just culture, when staff are not afraid to report the errors, the data of errors can be collected, analysed systematically in a structured manner such as through a RCA, learn important lessons from them and improve the systems and processes," they stress.

Private hospitals' perspective

Association of Private Hospitals of Malaysia president Datuk Dr Jacob Thomas says a hospital's leadership is key to ensuring patient safety.

It has to be fully committed and must also ensure that there is good awareness in the organisation in providing safe care, and this culture must trickle down to all staff members, he says.

Training and education of all healthcare staff is also important, he adds. "They all (without any exception) need to be aware, and conscious, of the importance of patient safety.

"It should be a culture. Patient safety is a huge issue and involves a lot of people and also conscious effort."

Dr Jacob also says orientation of staff at any hospital is also important to allow the individual to know and appreciate "how the hospital works", including its policies and procedures such as the seemingly simple aspect of not allowing visitors and even some staff to enter any unauthorised or restricted area.

"This is necessary to keep both patient and ward safe," he says.

It is important to document and review all incident reports as part of a system of ensuring continued patient safety, he stresses.

"There were some staff who were afraid previously to report incidents for fear of being penalised or reprimanded. If similar incidents keep repeating, then it is an indication that there are possible unsafe practices. What we do today is to find out the cause of these incidents and also find ways in which these mistakes can be prevented," he says.

If a hospital shows a sudden increase in reporting of incidents, it does not always mean that the establishment is unsafe, he points out. It could be an indication that management is doing its job in encouraging the reporting of cases and working to improve systems for better patient care.

Dr Jacob also reminds that patients and visitors are also responsible in ensuring patient safety.

"Hospitals are dangerous places and they too are vulnerable to hospital-acquired infections. Children should not be encouraged to visit hospitals unless it is absolutely necessary. Using the hand sanitisers, which are available, to disinfect the hands before and after visiting a patient is most helpful in preventing the spread of disease," he suggests.