The number of medical litigations is increasing worldwide. That does not necessarily reflect the quality of healthcare givers as much as it reflects the public expectations and awareness. Implementing healthcare quality standards is a key factor in maintaining public trust and significantly reducing the medical errors, ultimately reducing medical litigations. A comprehensive Enterprise Risk Management Program, focusing on patient and staff safety, is what is recommended for all healthcare organisations to harbour and implement.
Medical error is a preventable adverse effect of care, whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, infection or other ailment. Medical errors happen when something that was planned as a part of medical care doesn't work out, or when the wrong plan was used in the first place. Medical errors can occur anywhere in the healthcare system hospitals, in clinics, outpatient surgery centres, doctors' offices, nursing homes, pharmacies or even in patients' homes.
Napoleon Bonaparte claimed that “physicians kill as many as we do Generals”. Frank Lloyd Wright wrote “The physician can bury his mistakes, but the architect can only advise his client to plant vines.” (New York times, 1953).
A landmark in the history of medical errors and patient safety is the report of the Institute of Medicine in 1999, ‘To err is Human’. The report estimated a yearly death rate in the United States between 44,000 and 98,000 due to preventable medical errors. These figures are higher than the death rate for Motor vehicle accidents (43,458) and Cancer breast patients (42,297). The total US National cost was estimated between US$ 17 bn and 29 bn (lost income, lost household production, disability and healthcare cost). Hospitals are thought to spend 10-15 per cent of their budget on medical errors.
How big is the problem?
According to the 2005 commonwealth fund International Health Policy Survey, it is estimated that 22 per cent of admitted patients in UK hospitals experience a form of medical error. This is estimated to be around 23 per cent in Germany, 25 per cent in New Zealand, 27 per cent in Australia, 30 per cent in Canada and 34 per cent in the United States of America.
Comparable figures are not available for the developing countries. In Egypt, there are around 1200 medical claims against physicians per year. In Kuwait the number is around 250, while in Saudi Arabia the number of studied claims in the year 2009 was 1356, 50 per cent of which were dismissed.
Under or non-reporting is the main reason for the unavailability of accurate medical errors data in the developing countries. This is mainly due to the unavailability of a robust reporting system with clear case definitions and accountability for reporting. The fear of litigation and the absence of a legal safeguard are added factors.
Can we prevent medical errors and hence litigations?
It is of extreme importance to define the common causes of failures in the healthcare environment in order to prevent errors from happening. Root cause analysis is the preferred method to highlight the real causation. Individual staff negligence, on the average, constitutes less than 10 per cent of the root causes for medical errors. Therefore 90 per cent are correctable system issues that need the utmost attention of healthcare organisations. Communication failure is the leading root cause followed by lack of proper orientation and on the job training, proper patient assessment with missing vital information, staff credentialing, privileging and competency assessment, compliance with policies and procedures, safety of the environment, leadership, lack of care continuum and care planning and finally the organisations own culture. Physicians and nurses usually fail to communicate due to a historical hierarchical issue, past and vast experience of nurses and their level of empowerment and finally due to the different personal communication styles.
A comprehensive enterprise risk management programme, focusing on patient and staff safety, is what is recommended for all healthcare organisations to harbour and implement.
Enterprise risk management and patient safety
In general, risk management is the process of identification, assessment, and prioritisation of risks followed by coordinated and economical application of resources in order to minimise, monitor, and control the probability and / or impact of unfortunate events or to maximise the realisation of opportunities. In enterprise risk management, a risk is defined as a possible event or circumstance that can have negative influences on the enterprise in question. Its impact can be on the very existence, the resources (human and capital), the products and services, or the customers of the enterprise, as well as external impacts on society, markets, or the environment.
There are 2 main approaches to risk management
The proactive approach: Works on forecasting and identifying risks and designs or implements well known and tested solutions to prevent it from happening. This approach has shown by time to be the most effective, but requires a lot of skills and experience.
The reactive approach: Where all errors are collected and analysed, focusing on finding common system issues that could be corrected in order not to repeat the same error. It is much simpler than the pro-active approach but still requires skills, dedication and expertise.
Proactive risk management
Improve communication
Most organisations find the I-SBAR communication acronym to be a very useful pro-active tool to be utilised in all patient care related communications. It definitely eliminates the nurse / physician sensitive issue as well. The acronym stands for
“I” : Introduce yourself and the reason for calling
“S” : Situation for the patient (age, gender, general condition)
“B” : Background of relevant details, including medical history
“A” : Assessment and the related findings
“R” : Recommendation/request
Failure of hands off written communication between shifts
This is a well-recognised cause for medical errors. Hands off communication occur between the same category of healthcare givers (for example physician to a physician) at the end of a shift or the beginning of a new shift. The Agency for healthcare research and quality advocates the use of the ‘Five Ps’ for hands off communication which stands for: patient, plan, purpose, problems and precautions.
Multi-disciplinary patient care meetings
At times the most responsible physician is unable to reach a diagnosis or formulate a definite plan of care for his/her patient. This is the time to call for a multi-disciplinary meeting involving all healthcare givers looking after the patient and also to invite suggested specialities that may help in solving the problem at hand. It is best to involve the patient/family in the outcomes of the meeting with full explanation so all agree on what is required to be done. The meeting is to be carefully documented in the patient's file, including the patient / family understanding and agreement.
Standardised verbal and telephone orders
This is a common cause for errors related to receiving test results or orders. Verbal orders should be limited to emergency situations when there is no time to appropriately write the order required. The staff receiving the order should acknowledge hearing the correct order by verbally repeating it to the ordering staff. The ordering staff should immediately write the order as soon as the emergency is over. Telephone orders should be repeated in a read back fashion, whereby the receiving staff immediately writes the order in the file and reads it back to the ordering staff.
Credentialing and privileging
The credentials of each and every healthcare giver should be carefully studied by a group of experts to ensure that the staff has the right qualification and experience necessary to carry on the job description of the desired post. It is of utmost important to check on the authenticity of the evidence of qualifications and experience by contacting the source where the certificate originated from. Physicians are assigned what their qualifications and experience allows them to perform in clinical practice (privileging). This could be further categorised to include what is allowed to be performed with and without supervision to enhance their training. All privileges has to be available to all ancillary staff in areas where procedures are performed, in order to ensure that the physician is performing what he/she is allowed to only. The process of credentialing and privileging should be periodic to cover the initial assignment period and any further contract renewals and it also has to be flexible to allow for revision of a physician's privilege or credentials when the need arises (recent morbidity, new certification in a procedure or a new qualification).
Development, use and monitoring of clinical practice guidelines and clinical protocols
Evidence-based guidelines and protocols, targeting the management of high risk diagnoses, the high volume or the problem prone cases, have proven to improve clinical outcomes. It also serves as a legal back up in a court case.
Accountability of the attending physician
It is important for attending physicians to review all consultative orders and plans requested by other physicians and healthcare givers to ensure uniformity of care and avoid conflicts in plans. Coordination of care, for example by case managers, does not substitute the accountability of the attending physician.
Professional development
This is an integral part of any human resource plans. Organisations should always encourage the staff to seek higher degrees and training by providing them with time and opportunities for learning.
Standardised assessment and re-assessment forms
To ensure that all information required for patient management is available at any time for all healthcare givers.
Electronic medical records
In addition to its great value in standardising the process of documentation, it also provides a safer platform for medication management as it eliminates transcribing errors, alerts physicians of possible interactions, maintains a drug profile for each patient and helps in administering the right drug to the right patient in the right dose and format and at the right time and saves a confirmatory document.
General orientation and on the job orientation: New comers have to be given enough time to orient to the organisation and their area of assignment. Hospital general orientation program should be based on quality standards that affect patient and staff safety, in addition to the general employee relation issues that interests new staff. Departmental orientation is meant to focus on how the staff can perform their duties in the most effective and efficient way, including the different interactions with other departments.
Ongoing monitoring and evaluation of staff performance
It is very important to have an objective assessment tool that highlights areas of weakness in the staff members for further improvement. This tool includes, but not limited to, personal interactions, reports on clinical outcomes (length of stay patterns, ordering of blood and blood products, operating times and patients' returns to operating room, significant morbidity, preventable mortality, compliance with patient safety goals), self-professional development and quality of medical records documentation.
Optimising staffing levels
Overworked and exhausted staff are liable to make mistakes. Staffing levels should follow acuity of care rules as well as the nature of practice.
Patient safety goals
Implementation and monitoring of patient safety goals has proven to reduce errors related to patient identification, communication, the use of high alert medications, wrong site, wrong procedure, wrong patient surgery, patient falls and healthcare acquired infections.
Leadership rounds
When constructed in an educational format helps leaders to identify staff weaknesses and assures staff of the continuous support to quality from leaders. Further educational programs can be designed according to common findings.
Structure and process design
It is very important to realise that patient outcomes are very much linked to the way a procedure was designed to be executed or the design of the place where the procedure takes place. Therefore, any new procedure to be modified or introduced to the organisation or a modification to an existing area or constructing a new procedure area has to be studied carefully by a multidisciplinary group that have the skills and knowledge to reach a safe procedure or design.
Active patient and family education and participation in the care process
A well-informed patient and family can rarely complain about outcomes, especially with effective documentation.
Reactive Risk Management
Healthcare organisations must track all incidents, morbidities and mortalities. Risk management team should be involved in analysing all such events and putting together corrective system recommendations to prevent it from recurring. Hospital staff should receive a periodic feedback on the events and a summary of the recommended corrective actions. Examples of the possible tracking methods include:
Finally, it is obvious that all this requires a change in the culture of organisations and individuals to move from a physician oriented and controlled practice into a team work within the borders of an evidence based system of patient and staff safety. A system where transparency is the rule and information is shared in order to establish further improvements and actively prevent errors from happening.
Hossam Ghoneim is the Executive Director for Medical, Clinical and Nursing Affairs for one of the largest private healthcare organisations in Saudi Arabia (Dr. Soliman Fakeeh Hospital). He is also an Intermittent Consultant for the Joint Commission International. He has over 17 years of leadership and management experience in healthcare, experience in quality management and patient safety and 25 years of clinical experience in Obstetrics and Gynecology and Women's Health.
