PATIENT SAFETY AND CLINICAL COMMUNICATION

PATIENT SAFETY AND CLINICAL COMMUNICATION. PROF. LAL REHMAN FCPS, FRCS JINNAH POSTGRADUATE MEDICAL CENTRE.

In the early years of the safety field, the target was errors, and we focused on measuring and decreasing error rates. This model has given way to a new focus on measuring and attacking “harm ” or “adverse events” where harm is the “outcome” and errors are the “process.” After all, patients, quite naturally, care more about what happens to them than whether their doctor or nurse made a mistake..

We need to differentiate complications (adverse events that arise from the underlying disease) from medical harm (unintended injury caused by medical care). Not all adverse events are preventable , and those that are, usually involve errors. An error is “an act of omission (doing something wrong) or omission (failing to do the right thing) which may lead to or which causes an undesirable outcome.”.

Many errors do not result in adverse events and these are called ‘near misses’ or ‘close calls’. When the error is a result of care that falls below a professional standard of care, it’s called negligence ..

Learning from our mistakes. We need to openly acknowledge that errors are an integral part of the human experience. This will allow us to radically transform our approach to medical error. After all, one of the best ways to improve oneself is to recognize mistakes and to learn from them. The same strategy applies to providing the best patient care possible, and we need to treat medical errors as a treasure, rather than try to hide them, or shy away from discussing them..

Safety has to do with lack of harm. Safety focuses on avoiding bad events. Safety makes it less likely that mistakes happen. The ‘patient safety first’ culture needs to become part of the DNA of the healthcare system. This means committing to safety at all levels of the health facility, right from the frontline staff to doctors and nurses as well as the board of directors..

To err is human. Human error implies that if the medical team member had acted differently, the injury caused to the patient could have been prevented. We all make errors – after all, that’s what makes us human! Jens Rasmussen has suggested that errors occurred due to deficiencies in either one of the following: Skills (e.g. asking an inexperienced doctor to perform a laparotomy without supervision); Observation of rules (e.g. not washing hands before performing a procedure); or Knowledge (e.g. being unaware that gentamicin levels in the blood need to be checked)..

The truth is that medical errors can occur regardless of a doctor’s vigilance, good intentions, skill , experience or expertise. This is because medical care is a complicated system, and complex systems do fail unpredictably. What we need to do is to work on the system, so that it becomes easier for doctors and other healthcare professionals to go about discharging their duties in a more efficient, error-free manner..

Types of errors. This is the dominant model for understanding the relationship between active (“sharp end ”) errors and latent (“blunt end”) errors . Latent errors - These are the hidden root causes in the system that make active errors more likely to happen – for example, poorly designed medical records, making it easy for clinicians to misunderstand reports; or inadequate staffing, making people “rush” or routinely “multitask ”. Active errors - These occur at the level of the healthcare provider – the frontline staff that actually delivers the services, and can cause harm. These are what we think of when we think of error, due to the focus on individual acts in medicine..

Active errors can take the form of slips (doing a familiar action in the wrong way, like pouring salt instead of cream into coffee), lapses (failures of memory such that planned actions do not happen), and mistakes (errors in reasoning that lead to wrong choices). They are easier to measure because the negative outcome is much more apparent – for example , the nurse injects the wrong medication; or the doctor amputates the wrong leg..

TYPES OF MEDICAL ERRORS Errors from unintented action Attentional failures Memory failures Medical Errors Errors from intended action Violations I. Rule based Purposeful errors mistakes like 2. Knowledge sabotage (rare) based errors.

How can we make the system safer?. Here are some basic principles. Automate when appropriate Standardize – reduce reliance on memory Use checklists & standard operating procedures (SOPs) Simplify by reducing the number of steps and handoffs Add redundancy (double checks) for high-risk processes to create a safety net Stress-test the system, and try to break it, to find out the “failure points” so that these can be reduced and removed Respect the front-line staff, who are the real-life field experts, and ask them what can be done to help them do their work safely.

P atient E mpowerment - Knowledge is power!. The first conclusion most people jump to when a medical error occurs is – It was the doctor’s fault ! Patients still think of themselves as being passive recipients of medical care who are at their doctor’s mercy. However, you need to take an active role in your medical treatment, and behave as an enlightened partner - after all , your doctor is not a veterinarian ! Patients can be the first line of defense against errors, and there’s a lot you can do to protect yourself . Patient safety is not just the doctor’s responsibility – it’s the patient’s as well. Patients must play an active role in preventing medical mistakes..

An empowered patient is the CEO of her health team.

Misdiagnosis as a cause for medical errors. Doctor Most doctors know only the common diseases Different doctor skill levels Doctor bias Saving you money Lack of time Some symptoms are hard to analyze Laboratory tests and imaging studies Human errors False positives and false negatives Misinterpretation Poor quality labs Patient Self diagnosis Not reporting symptoms Failure to perform the ordered tests.

What can be done to reduce diagnostic error and harm?.