What compromises patient safety: a WHO primer
M3 India Newsdesk Apr 24, 2018
Patient safety is growing to be a global health concern, with the need of the hour being joint efforts to decrease safety risks in the healthcare setting and deliver quality healthcare in a highly charged environment.
Patient safety while being a fundamental principle of healthcare, is also a serious health concern worldwide. The World Health Organisation (WHO), estimates that 1 in 300 patients are being 'harmed' while availing health care. Moreover, approximately 43 million patient safety incidences occur every year. This can result in longer stays in the hospital, a permanent disability or even death for the patient.
- WHO states that throughout the health-care industry, the failure to correctly identify patients continues to result in medication errors, transfusion errors, testing errors, wrong person procedures, and the discharge of infants to the wrong families.
- WHO further highlights the existence of confusing drug names as another common cause of medication error that compromises patient safety. A potential reason for this is the availability of a large number of drugs on the market.
The potential for error due to confusing drug names is significant. This includes non-proprietary names and proprietary (brand or trademarked) names. Many drug names look or sound like other drug names. Contributing to this confusion are illegible handwriting, incomplete knowledge of drug names, newly available products, similar packaging or labeling, similar clinical use, similar strengths, dosage forms, the frequency of administration, and the failure of manufacturers and regulatory authorities to recognize the potential for error.
- Catheter and tubing mis-connections is another area that calls for standardised protocols to protect patient safety. The current design of these devices allows to inadvertently connect the wrong syringes and tubing and then deliver medication or fluids through an unintended and therefore wrong route.
- Wrong site procedures like the wrong organ, wrong implant, and wrong patient also occasionally contribute to compromised patient safety.
- Another area of concern for patient safety is the use of unsafe injection practices.Primarily reuse of syringes and needles or contamination of multiple-dose medication vials are known to be responsible for this.
In the healthcare setting, it is commonplace for a patient to move between areas of diagnosis, treatment, and care and encounter different staff each day. This potentially increases the safety risk to the patient as each hand-over communication between units and between and amongst care teams might not include all the essential information, or information may be misunderstood. These gaps in communication can cause serious breakdowns in the continuity of care, inappropriate treatment, and potential harm to the patient.
A real story of harm from a medication error
A couple took their two-week-old baby girl for a routine check-up. The paediatrician ordered two injections of vitamin K. The nurse gave the baby one injection and passed the second vial to the parents. On their way home, the baby cried continuously. When she suddenly stopped crying, her parents realized she was no longer breathing. They rushed her back to the clinic, where the staff immediately began to resuscitate. The baby girl died later that afternoon.
As the grieving parents tried to understand what had happened, they looked at the vial of medicine they had remaining. It said EPINEPHRINE. They realized their baby had not been given vitamin K as they had thought. Clinic staff told them that the vitamin K and epinephrine bottles were similar in size and colour and were easy to confuse.
“Look-alike” packaging is an ever-present challenge in dispensing of medications.
Reference-Patient Safety: Making health care safer. Geneva: World Health Organization; 2017.
Standardising protocols and procedures can help avoid most of the above-listed errors. Patient safety is not only important for patients, but it also helps the doctors and the healthcare team to practice safer and better medicine.
WHO Facts about the patient safety :
Fact 1: Inappropriate patient safety is the 14th leading cause of death across the world. An estimate says that around 42.7 million adverse events occur in patients during hospitalisation.
Fact 2: Almost 1 in 10 patients in High Income Countries (HIC) faces harm due to an incident or adverse event during a hospital stay. The rate of adverse events in low-and middle-income countries (LMIC) is around 8%. The point of consideration here is that almost 50% harm in HIC and almost 83% harm in LMIC were preventable.
Fact 3: Medication errors harm millions of patients while wasting billions of dollars every year. Almost 1% of global health expenditure is wasted due to medication errors. These errors can be due to weak medication system or due to certain human factors like shortage of staff, miserable working ambience, exhaustion of the person in position or interruption in the workflow. Eventually, these factors will cause inappropriate prescription, transcription, dispensing, administration and checking of medicine resulting in medication errors.
Fact 4: Almost 15% of total health expenditure is wasted in dealing with adverse events like venous thromboembolism, infections, pressure ulcers etc.
Fact 5: Precise care and optimal investment in efforts to reduce patient harm can lead to significant financial savings as well as improved patient outcomes.
Fact 6: Healthcare associated infections affect 14 in 100 admitted patients worldwide. These can be prevented or reduced by more than 50% by following simple yet low cost measures of infection control like appropriate hand hygiene.
Fact 7: An estimated 7 million patients suffer from surgical complications every year, out of which around 1 million die. Surgical morbidity and mortality can be controlled by improving patient safety during every stage of surgery.
Fact 8: Wrong or delayed diagnosis or the treatment affects a large number of patients. It is estimated that almost 5% of patients experience an error in their diagnosis every year in the US. Also, a review of the medical records indicates 6-17 % of diagnostic error of all the adverse events. This can be attributed to factors like limited care and diagnostic resources, under qualified caregivers etc.
Fact 9: Though ionizing radiation has greatly improved healthcare its exposure is a cause of health and safety concern.
Fact 10: Administrative errors related to systems and processes or care delivery account for around 50% of all medical errors in primary care.
How to ensure patient safety
Use of standardised Patient Safety Solutions (WHO, 2007) for healthcare professionals help to prevent potential errors from reaching the patient. These interventions have demonstrated the ability to prevent or mitigate patient harm.
- Providing clear protocols for identifying patients who lack identification and for distinguishing the identity of patients with the same name is recommended by WHO.
- Non-verbal approaches for identifying comatose or confused patients should be developed and used.
- To avoid catheter misconnections, the best solution lies with introducing design features that prevent misconnections and prompt the user to take the correct action. Though designing physical barriers such as incompatible of design can help avoid such errors another simple approach could be specific labeling of device ports which will help to avoid connecting intravenous tubing to catheter cuffs or balloons.
- The WHO report advocates encouraging patients and families to ask questions about medications given parenterally or via feeding tubes, to assure proper medication delivery.
- To avoid hand-over communication errors, streamlining and standardising change-of-shift reporting is recommended. It is believed to enhance critical thinking. Similarly, read-back is another effective technique used in hand-overs. The receiver of information writes down the information and then “reads it back” to the provider of the information to obtain confirmation that it was understood correctly.
- Hand hygiene is yet another fundamental action for ensuring patient safety, which calls for meticulous adherence,in a timely and effective manner in the process of care.
Read the whole WHO report on Patient Safety here.
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