Ensuring Patient Safety
Monitoring patient safety is very important, though not easy. It requires strong commitment and serious action from all parties, including the public. A patient safety program should be implemented immediately.
World Patient Safety Day (WPSD) was observed a few days ago on 17 Sept. On this occasion, the need for global action to prioritize patient safety was reiterated.
Prior to 1990, patient safety was not given much attention. The situation changed after the Institute of Medicine (IOM) issued a report in late 1990 that 44,000-98,000 hospital patients in the United States die every year due to medical error. The report was shocking.
No one had expected that the magnitude of medical error was that large. The reports that followed were even more surprising. Several years ago, Johns Hopkins University released information that more than 250,000 people died annually in the US due to medical error. This figure exceeds the number of deaths from lung disease, which is around 150,000 per year. According to these figures, medical error is the third killer in the US after heart disease and cancer. It is even said today that getting hospital treatment is more dangerous than handling weapons.
Complexity vs limitations
Errors can occur at any stage of medical care. There are various types, from negligence of health workers to wash their hands before a procedure to medication error, from inaccurate diagnosis to complications from a procedure. Every medical error, no matter how small, is a potential threat to patient safety. Patients can experience severe complications, disability and even death.
Therefore, medical error must be kept to a minimum. In fact, medical error is still rampant. According to the World Health Organization, one in 10 patients in developed countries risk a threat to their safety receiving hospital treatment. In developing countries, 134 million incidences of medical error occur in hospitals each year, resulting in 2.6 million deaths. At the global level, four out of 10 patients are at risk while receiving medical treatment, and five people die from medical error per minute. AT this magnitude, medical error is the fourth greatest killer in the world after heart disease, stroke and obstructive pulmonary disease.
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A number of conditions facilitate the occurrence of medical error, including an imbalance between the complexity of medical services and the ability of health workers to respond to that complexity.
Medical services everywhere, including in Indonesia, involve complex systems. First, various stakeholders are involved in medical services. At the topmost level are the Health Ministry, professional organizations, health insurers and other stakeholders that contribute to the creation of laws, regulations, and standards as regards medical services.
In the field, various professionals work to serve patients, including doctors, nurses, and laboratory workers. Each professional has different duties and responsibilities. Their number also varies from one institution to another, and can be in the tens, hundreds, or even thousands. The complexity of this network necessitates optimal communication and cooperation between professionals; otherwise, medical error can occur easily.
Second, disease diagnosis and management is very diverse. When serving patients, health workers are required to make accurate diagnoses. This is not easy, because there are so many types of diseases. The WHO’s International Classification of Diseases 9 (ICD-9) contains a list of more than 15,000 diseases, while Malacard lists 18,000 diseases.
Most of these diseases cannot be diagnosed without further medical examinations. The problem is, additional testing is not always available. Finally, health workers often rely only on physical examinations to determine a diagnosis and so risk misdiagnosis.
Third, most patients are in an unstable condition when they come in for treatment. The course of a disease can fluctuate, and this is sometimes difficult to predict. The more unstable a patient's condition, the more complicated their treatment. Health workers must be very careful and meticulous in determining the course of action. The type of action and dosage need to be considered carefully. Otherwise, instead of improving the patient's condition, the chosen course of action can actually threaten their safety.
Fourth, the medical world is developing very rapidly. There are new developments almost every day. Operational guidelines and standards of action change regularly. What was practiced a few years ago may be outdated today. Health workers must be constantly updated in order to provide the appropriate treatment and action. Otherwise, the chance for medical error and threats to patient safety is wide open.
On the other hand, health workers are ordinary people. They are not machines that can constantly adapt and anticipate the complexities of medical services. They can be overworked and exhausted, making them forgetful or neglectful in following the standards and hence, can make mistakes. Health workers also have families and deal with life's problems. Their concentration may fall and their health is not always excellent.
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This is especially so if they are given a workload that exceeds their capacity. It is not uncommon to hear that health workers must work overtime and double shifts due to staff shortage. Some are even forced to take medical action with minimal facilities. Various factors create opportunities for error. These human limitations make health workers vulnerable to making mistakes. The concept of “to err is human” accurately describes this condition.
The conflict between the complexity of services and the limited capacity of health workers to respond has raised a need to avoid relying solely on human beings for patient safety. In order to maintain patient safety, there must be a system that can back up potential errors made by health workers, similar to a safety valve. This system can be in the form of hardware or software and must be multilayered.
To prevent medication errors, for example, the process of prescribing and administering drugs must have several layers of protection. The first layer is that the doctor must make the right diagnosis. If the doctor misdiagnoses, the patient's safety is placed in jeopardy. The second layer is in the prescription system. Prescriptions should preferably be electronic, equipped with an automatic warning system if the dosage is incorrect or has a potential drug interaction. On receiving such a warning, a doctor can decide whether to continue with the original dose or change it.
It is necessary to clearly explain how to use the drug and instruct them to stop the drug if they experience unexpected effects.
The next layer is the pharmacy. Pharmacists must run crosschecks to make sure the drugs and dosages match the patient's health complaint. If they do not, the pharmacist must communicate this to the doctor.
The last layer is the patient and the patient’s family. It is necessary to clearly explain how to use the drug and instruct them to stop the drug if they experience unexpected effects.
Combining these four layers of protection can minimize medical error. The more layers of protection, the less chance of a threat to patient safety. These various layers of protection are known as the Swiss Cheese Model.
Systemic errors
In the traditional course of delivering medical services, it is typical to blame health workers for any mistakes that occur. After all, they are the ones who take action. Health workers are easily blamed for making individual mistakes (human error). In fact, only 10 percent of medical error incidences are caused by human error. In almost all incidences of medical error, the root problem always involves a systemic error.
An emergency room doctor was easily accused of human error when he instructed a nurse to give a patient a diclofenac injection, after which the patient dies. On investigating the incident, it turned out that many systemic elements were contributing factors: the doctor was the only one on duty that day and had worked more than 15 hours, the patient load exceeded capacity, and the attending nurse was also the only one on duty and had worked multiple shifts. At the same time, some of the drugs needed to treat shock were expired and unusable.
In such a condition of vulnerability, the doctor and nurse neglected to ask the patient about any allergies and were unable to provide adequate support when the patient went into shock. This case shows that, even though it appears on the surface that the doctor made a mistake, various systemic factors caused the doctor to make the error.
To minimize the potential for medical error, hospitals should have a system to back up potential errors. The systems approach is critical to ensuring patient safety. This approach can identify and correct those systemic elements that can be potential causes of medical error.
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Regarding the case above, hospitals should have regulations that prohibit doctors and nurses from working more than eight hours a day or double shifts. Hospitals must also have backup health workers who can assist when there are too many patients. Emergency medicines must always be available and be updated for use. This systems approach can prevent drug errors.
The systems approach must be layered and adapted to the scope of the institution. For hospitals, it is usually more complex. In terms of resources, for example, it is necessary to provide enough health workers to match the existing workload. These health workers need to be trained on a regular basis to communicate effectively in their work.
In termes of facilities, institutions need to use electronic prescriptions and reporting through electronic medical records. Even if this facility is not yet available, efforts must be made to close the gap in potential errors in manual prescriptions and reporting methods. Services in the injecting room must be preceded by filling out the patient’s allergy history, obtaining informed consent and rechecking the injection before it is given.
Any pandemic must be controlled as much and as soon as possible.
The validity of drugs need regular checking. At the same time, it is necessary to develop a habit of reporting every incident and error that occurs (incident disclosure) as a lesson, not to punish wrongdoers. This kind of culture can make health workers more aware of the loopholes for making an error and try to avoid them.
Despite its very important role, the systems approach has not received serious attention in developing countries, including Indonesia. The reason is that this approach is too complex, cumbersome and costly.
Generally speaking, it is not economically profitable. This view needs to be corrected. The systems approach actually has a very good cost-to-benefit ratio and can minimize losses due to medical error. On a global level, medication errors alone cost US$42 billion each year. If the system can be corrected, errors can be reduced and losses minimized.
Monitoring patient safety is very important, though not easy. It requires strong commitment and serious action from all parties, including the public. A patient safety program should be implemented immediately, so incidences of medical error can be kept to a minimum. This is important, because incidences of medical error are rampant and pervasive. It can happen to anyone at anytime and anywhere. So it is not wrong that some experts call medical error a “non-disease pandemic”. And any pandemic must be controlled as much and as soon as possible.
Iqbal Mochtar
Iqbal Mochtar, Executive member of Indonesian Medical Association General Management (PB IDI) and Indonesia Public Health Experts Association Central Management (PP IAKMI), chairman of the Association of Indonesian Doctors in the Middle East (PDITT)
This article was translated by Kurniawan Siswo.
