Consultant Patient Safety and Risk Management SalSafe, UK
The need to consider and manage the safety of patients within healthcare has been widely recognised over the past decade. The ‘science’ of patient safety has grown, and is constantly seeking to identify how and why things go wrong in patient care and what we can learn from other industries and from other disciplines such as psychology to make care safer. The emphasis has moved away from ‘blame’ towards looking at how modern healthcare is delivered in complex, busy hospitals and clinics, and recognising that sometimes the systems themselves create problems.
What can go wrong?
The sort of things that can go wrong for patients are as varied as patients themselves and the people who care for them. This includes errors such as receiving the wrong drug or wrong site surgery, or complications of surgery and other treatments, or failure to diagnose correctly or to spot the patient whose condition is deteriorating and to do something about it.
The outcomes for patients can range from little or no harm and minor annoyance to permanent disability or death. The outcomes for families can be sudden bereavement; for clinicians involved in a serious error or incident can be loss of career, or even criminal charges, and lifelong distress. When all the evidence that is now being gained from wide spread studies of patient safety incidents indicates that a significant number of these are preventable, there is no excuse for failing to take patient safety seriously.
In specific incidents such as these, patients can be let down by healthcare systems which do not provide the best care. This happens only when clinicians do not keep themselves up-to-date with new developments in care, and do not review and change their own practice when there is evidence that other methods are more effective.
The basic principles for safety and quality of care
The basic principles for patient safety are the principles for quality of care: to do the right thing for the right patient using the right method and at the right time, and to communicate well with the patient and the rest of the clinical team—record findings, planning actions promptly and clearly, ensure that instructions are understood and carried out, and report concerns to a senior colleague when necessary.
These principles sound very simple, but most of the serious patient incidents result from a sequence of small errors or failures to act, rather than one large dramatic event. If each of these principles are analysed in more detail, the implications for both patient safety and good quality of care will become clearer.
Doing the ‘right thing’
This might mean ensuring that the correct test is carried out in line with the patient’s symptoms; that the correct drug is chosen and is given at the correct dose; that surgery is performed on the correct side of the body; and that observations are carried out on a sick patient at the correct frequency. The procedures and training to guide all the staff on various means to improve safety and quality of care—unambiguous and clear prescription of drugs, proper and safe administering of drugs, marking and preparing patients for surgery, knowledge of appropriate timing of tests and different methods of interpretation of results—should be provided.
The ‘right thing’ might also mean having up-to-date knowledge and skills to allow clinicians to give their patients the best care. Much of the patient safety activity in the USA and UK at the moment is focussed on good patient management—using proven methods to avoid ventilation pneumonia, for instance, or researching invasive procedures and frequently used drug regimes to see if they actually benefit the patient.
A classic example is to restrict the use of antibiotics to patients with bacterial infections rather than viruses, to reduce the spread of antibiotic resistance and opportunistic bowel infections. The need to do this has been recognised for decades, but changing practices can be painfully slow. All healthcare organisations need to consider how much they can rely on individual clinicians’ judgement and to what extent they can intervene with directives or by taking action to force compliance with changes.
The right patient
This sounds painfully obvious, but many errors occur because patients have similar names. Errors could occur when the wrong patient is taken to X-ray, or a doctor picks up the wrong set of notes, or specimens are mislabelled, or even because in a busy ward there is a new patient on the bed. It should be routine for staff to check at each stage of care that they are dealing with the correct patient, and if they have heard the patient’s name correctly when they are asked to carry out an instruction.
The right method
This includes, for instance, ensuring that diagnostic tests are performed and interpreted correctly. Similarly, many errors occur where drugs are given by the wrong route or in the wrong concentration. One very well known case in England involved a chemotherapy drug, Vincristine, being administered into the spine instead of a vein. When this happens it is always fatal.
Obviously all invasive procedures must be carried out by competent staff or staff under competent supervision. It is important that training and written procedures are in place to ensure that ‘right method’ is followed. It is also very important that untrained staff know that (and abstain from) they should not perform certain tasks which carry significant risks.
Ensuring the right method also means having systems in place to keep medical equipment clean and in good working order. Patients are safer when staff do not have to choose between similar pieces of equipment which work in different ways, such as one-hour and 24-hour infusion pumps. It is not always easy to standardise equipment, but when new equipment is chosen, ease of use and potential risks should be taken into account.
The right time
Again it seems obvious, but this includes giving drugs as prescribed and not getting confused by 24-hour clock. More subtle care management such as not giving a drug or treatment when there is a contraindication, checking the patient and recording observations when required, recognising the need for pain relief or other symptom control and acting promptly if the patient’s condition is deteriorating. Many hospitals in the UK and USA have introduced ‘early warning systems’ designed to alert staff about a deteriorating patient and to guide and empower them to seek senior assistance.
“In healthcare, information, especially the one related to a patient’s health, is key to the care provided. Faulty treatments, in most cases, can be attributed to improper communication of critical data.” This opening comment in the editorial of Asian Hospital and Healthcare Management Issue 16, illustrates clearly why good communication about patient care is as important a component of safety as all the treatments that a patient receives.
Other articles in that issue and recent editions talk about the need to communicate well with the patient and their family. It helps not only patients in understanding their condition but also healthcare providers in providing proper care to patients. Listening to what patients have to say and respecting their wishes forms the basis to healthcare in the 21st century. Moreover, patients who feel involved and in control of their care tend to do better, and more satisfied with the care they receive.
Many teams are involved in the care for patients in a modern hospital. This includes doctors, nurses, therapists, technicians, pharmacists. Their relationship with each other requires sharing of information and acting on instructions. The doctor or nurse on duty must know what was done to the patient the previous day and what is planned for the next day—and why. And in their shift they must record changes in the patient’s condition, results of tests, new plans for care and anything else that everyone caring for the patient needs to know.
The vital information remains useless if it is not shared. It will not be shared if records are kept in different places, or if different professionals keep their own records. Hospitals should review their systems for storing patient information and sharing it, through team reports, ward meetings or any other means. Many errors occur when messages are not passed on, or something is not written in the notes, or when what has been written is not clear and can be misunderstood.
There should be policies and training to ensure that all records are kept properly. The details of when and who should write in the records should be clearly mentioned. They should also specify the means to ensure that all the information is filed correctly and new information is seen (such as test results) and dealt with appropriately.
Good communication is important beyond the patient records—in how staff talks to patients, and each other. Many industries have learnt that it is important for safety to have a culture where no one is above criticism (because any human being can make a mistake) and where junior staff can put forward suggestions or concerns, and have these treated with respect.
Developing a patient safety culture and systems
This article has frequently referred to the need to have policies, procedures and training for patient safety. These are important, but they will achieve nothing unless they are part of a patient safety culture where everyone, from the most senior staff to the most junior, understands the importance of patient safety and why it matters.
Training of staff should show how everything they learn affects the safety of patients. Senior staff should lead by example—juniors will imitate what they do. Staff should understand why it is important that equipment is properly used; that infection control and hygiene are carried out properly; that instructions are clearly understood and followed; that prescriptions are written carefully; and so on.
One way of helping staff to understand about safety and learn from mistakes is to have an incident reporting system. When something goes wrong, the staff involved should be able to report what has happened without fear of undue blame, and the events leading up to the incident or error should be reviewed to know what went wrong, and to see if it can be prevented in the future.
Many useful lessons about safety have been learnt from similar incidents reported in different places. As a result, the common causes have been identified and the knowledge has been shared.
It can be useful to have designated staff with responsibility for coordinating all the patient safety activities; for instance, ensuring that policies are up-to-date and that staff receive training when they need to. But it is important that they are not seen as the person or team responsible for patient safety. The people responsible for patient safety are the members of staff who have anything to do with that patient—whether as doctor or nurse, therapist or technician, cleaner or cook, engineer or purchase clerk paying for drugs. Anyone who has a job in a hospital makes patients safer when they do their job properly, and work well as part of the hospital team.
Sarah Williamson is a registered nurse with special interests in clinical risk management, governance, organisational and cultural change, and staff development. She was Clinical Risk Manager at Sheffield Teaching Hospitals NHS Trust 2002-2007. She is a MA in Communication Studies and currently a freelance consultant in patient safety. She is regular conference speaker and has published several articles.