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Patient Safety: The delivery of health care as a science [Kuwait Times]
[June 08, 2014]

Patient Safety: The delivery of health care as a science [Kuwait Times]

(Kuwait Times Via Acquire Media NewsEdge) Dr Nancy Thomas KUWAIT: Dr Nancy Varghese Thomas is a dentist and a healthcare management professional. She did her masters with two majors in public administration and healthcare management from US. She also has CPHQ certification offered by NAHQ and various certifications from other healthcare organizations. She has a passion for patient safety and quality, one of the founder members of the ASPPS (The American Society of Professional in Patient Safety) and also associate member to many other healthcare professional organizations. She has worked with the pioneers in the field of patient safety while being at Harvard. She has been involved with various organizations in Kuwait and is currently a patient safety and quality improvement consultant and a speaker. She has to her credit implemented customized safety surgical protocols that has been approved and have been listed by WHO, which are now followed in certain hospital.

She has a keen interest in teaching as well as doing further research in this field. She conducts workshops in order to educate the healthcare providers and implementation of strategic plans.

Healthcare is A….System made up of thousands of inter-linked processes…. things can go wrong!! "To Err is human and is inevitable but most errors are preventable".

We humans like to showcase our achievements but would we be courageous to project our errors in public?  Would our conscience help us to think that by sharing our mistakes we are helping others not to commit the same? If we all shared our errors, would we be in safe hands today? Have we overlooked our errors and accepted the mistakes to be a part of our daily lives? How many times in our lives have we been close to a near miss due to an erroneous system? Even if one discloses his errors, would he be judged as incompetent or would his experience be taken as a learning curve for improvement? 1. What is patient safety? There is a science of health care delivery which engulfs these kinds of thought processes and it is called the Patient Safety and Quality Improvement.

In the early days it was called Quality Assurance. With time it came to be known as patient safety and quality improvement, where patient safety is the scientific approach to keep the patient safer and quality improvement is the ways or means to attain the goals.

Initially, the two parts, safety and quality, used to be clubbed together. However, since two years, Patient Safety has had its own certificate examinations.

A Simple definition of Patient safety is freedom from accidental injury due to medical care or medical errors by Institute of medicine (IOM), 2000 2. Why did patient safety evolve? In 1999, an IOM report "To Err is Human: Building a Safer Health System"  caused an awakening in the health field which states that a staggering estimation of 98,000 patients died annually from medical mistakes; this shook the U.S. healthcare system even though it was based on studies done up to a decade earlier. This in turn was the key eye opener in pushing experts to take this aspect of medicine more seriously and has become one of the thrusts behind the current patient safety and quality movement which stands out to be a discipline of its own.

This report pointed out a lot of medical common unseen errors using statistics which raised a lot of questions on ones professionalism. One of the key remarks made was that in the US 48,000 to 90,000 people died in hospitals as a result due to medical errors!!! To remind you that it was only in hospitals. If it was taken into account of those discharged, the statistics would have been even more staggering. These figures are comparable to a jumbo jet crashing every day in a year. In other words the number of people dying of preventable harm due to medical errors were much greater than people dying of let's say breast cancer, AIDS or any of those terminal illnesses.

3. What do you mean by medical errors to put things in perspective? The fundamental principle though out the health care is "First, do no harm".

"To Err is human and is inevitable but most errors are preventable".

A simple definition of error is "Doing the wrong thing when meaning to do the right thing". Errors depend on two kinds of failure, first is actions do not go as intended and second is intended action is not the correct one.

One of the main reasons for possible errors are due to human fatigue in any field of work.  Higher the position leads to more pressure which in turn is a domino affect from stress to fatigue. In the medical field doctors are generally over worked due to long working hours which lasts a straight more or less to 24 hours. Long hours such as these would not allow one to function to the best of our ability. With these kinds of working conditions the possible errors could be that the doctor misses out on various queries like asking the patient if any other doctor has been consulted or any other treatment modalities have been prescribed. In such a situation either a double dosage or a drug reaction could occur which could be sometimes fatal.

4. Can you describe a scenario and how was it dealt with? A simple scenario could be: the health care provider prescribes a drug, while the pharmacist dispenses the drug to the bedside caregiver to administer the drug. Clearly this is a complex system for a single medication dose, as errors can occur at any given time. To make it more specific an error could be due to illegible handwriting while the pharmacist dispenses the wrong drug or the verbal communication misinterpreted, the drug itself could create an allergic reaction and in the worse come scenario the patient dies. This is just to make an understanding of the ways to complicate it by one mistake which can lead to a major disaster. This is one of the probable medical error. While most commonly occurring adverse event in the health care are medication errors and the needle stick injury.

As we probe deeper into the medical errors, we find that most of the time the reason would be very simple and preventable. If we have to ensure reliable practices in health care we need to simplify the number and complexity of the steps in the care we deliver. A stable process in health care typically is 40% to 70% reliable. Other high risk, complex industries strive for 99% and higher.  Health care needs a range of strategies to improve reliability.  There is a quality improvement process called Root Cause Analysis (RCA) which is generally carried out on the adverse events occurred to further improve the process.

5. What are the measures taken by the healthcare organization to ensure that errors are negligible? Every hospital can follow their own well defined policy and procedures, protocols or systems but to ensure that standards are met, it is better to go through a volunteer process of accreditation. That is where the accreditation comes into play, which is nothing but maintaining high standards or improving quality which in turn makes the institution to maintain standard protocols thereby making it less prone to errors. This accreditation body for hospitals in the US is TJC (The Joint Commission). Today their standards are well recognized and more than 60 countries have TJC accredited hospitals in the world. To maintain their accreditation the volunteering organization has to have approved minimum standards met.

To name a few commonly known accreditation bodies to this part of the region are:  Joint Commission International (JCI) and Accreditation Canada (AC).

6. How does this accreditation processes help patient safety? TJC established the National Patient Safety Goals (NPSGs) program in 2002.  Purpose was to improve patient safety and the goals was to help accredited organizations address patient safety concerns.

JCI's 2014 NPSG are to identify patients correctly, improve staff communication, use medicines safely, use alarms safely, prevent infection, identify patient safety risks, and prevent mistakes in surgery.  When the goals are implemented throughout the system, it then becomes a standard. In 2014, patient falls and pressures ulcers were made part of the standards.

JCI requires accredited health care organizations implement NPSG's as appropriate to the services provided by the organization.

These different accreditation bodies have their own patient safety goals which have to be met by the volunteering institutions. JCI calls their goals "National Patient Safety Goals (NPSG)" & AC calls it "Required Organizational Practices (ROP)". In Kuwait, Ministry of Health follows a set of goals which is known as the "Nine Patient Safety Solutions".

7. How does one report an error? Generally at work, there is a lack of transparency and has a punitive culture. People would not want to upset their superiors and risk their jobs by reporting on errors. Therefore, the first step towards patient safety culture is to have the support of leaders or management, while having an ideal situation to develop a culture of learning from mistakes, encourage being transparent to speak up, be non-punitive and empower the employees.

For instance, if the system follows a punitive culture, then the employee would be reluctant to open up with their mistakes. An example would be needle pricks (to prick oneself by accident) among nurses is quite common during loading or discarding a syringe. In this case these repeated mistakes go unaccounted for but instead if they were encouraged to report an error without any fear then the likeliness to evaluate, educate and eradicate a common error would be possible.

8. Has technology helped in minimizing errors for patient safety? Technology is indeed a blessing to healthcare industry in many ways. The relation between the patient safety and technology is through the role of electronic health records and other devices used for delivering the care.

In health care, this would refer to the practical and applied methods that facilitate the delivery of care for patients, families, and providers.

An electronic health record (EHR) is a real-time, point-of-care, patient-centric information resource for clinicians1 that represents a major domain of health information technology (HIT). More recently, an EHR has been defined as "a longitudinal electronic record of patient health information, produced by encounters in one or more care settings." It includes patient information such as a problem list, orders, medication, vital signs, past medical history, notes, laboratory results, and radiology reports, among other things. The EHR generates a complete record of a clinical patient encounter or episode of care and underpins care-related activities such as decision making, quality management, and clinical reporting. Some distinguish between the terms EHR and electronic medical record (EMR), with EMR focusing on ambulatory care systems. However, in practice, the terms are interchangeable.

Technology in the acute and critical care settings are bedside monitors, computerized provider order entry (CPOE), Bar code medication administration system (BCMA), wristbands, mechanical ventilators, dialysis machines, point-of-care testing, infusion pumps, ventricular assist devices, and computerized information systems. Most of them are clinically oriented but a few are worth mentioning.

CPOE helps medication and provider order safety by using software to make provider orders legible and the use of standardized treatment plan.

Wristbands must be used for all patients and in maternity wards for both the mother and the baby so that switching or abductions of babies can be prevented. Whether in an NICU or in a nursery, it is next to impossible without the wristband matching. This is why these days it is highly unlikely to hear of such stories where the mother was handed the wrong baby on discharge from the hospital.

8. What are the improvements made in the field of communication especially between the patient and the provider? Though there is still a huge room for improvement. We have a program called the "Ask Me Three." It is a program for patients; the providers wear a badge saying "Ask Me Three." Through this we are creating awareness among the patients to ask 3 important questions to the providers.

"Ask   Me 3? – by NPSF Ask these 3 questions to the provider. (Encourage the patients to ask) 1. What is my main problem? 2. What do I need to do? 3. Why is it important for me to do this? Speak up initiative: If you are caring for a family member or loved one, it's important for one to think of as his or her advocate. Being engaged and asking questions are probably the most important things you can do to keep your loved one and yourself safe from medical errors. Encourage health care workers never to assume the concept of "IT MUST BE RIGHT" about what another health worker is doing. If you have a hunch that something is wrong, interfere and ask relevant questions to make sure that it is right. Be alert to the potential for harm. 'Looking' does not always mean 'Seeing' – ask yourself what you might be missing. Question and report unsafe practices. Discuss these openly so they can be addressed promptly – you may save someone's life or prevent them from being harmed in our care. Identify opportunities to improve – sometimes the small things can make a big difference to the quality and safety of care. Share your improvement ideas with your team – every idea counts.

Read back initiative: This is another aspect of patient safety communication. We insist that the patient has to voice out the answer.

Thank you very much Dr. Nancy V. Thomas, it was a pleasure having you here with us on Kuwait Times. The information that you shared with us has been a real eye opener compared to the limits what we should know as a common man.

All rights reserved.

(c) 2014 Kuwait Times Newspaper Provided by SyndiGate Media Inc. (

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