Cause No Harm
  • Posted by Dr. Clive Fernandes
  • 16 Jan, 2017
  • 0
  • Featured

Putting systems in place is a trend the healthcare industry should follow to ensure every patient’s safety during their stay in the hospital

Some of the main causes for most events that occur fall into the below categories:

1. Lack of effective communication: Effective communication means the receiver of the information understands and acts on the information the way it is intended. There are many different forms of communication: verbal when both the care providers are in the same room, written or telephonic. In our daily life, verbal communication has been found to be the main cause of errors. Many healthcare organisations have policies limiting the use of verbal communication while delivering patient care to emergency situations, but how often are these policies followed? They are perceived as a waste of time. A detailed RCA of any event will highlight how miscommunication was probably a leading cause of the event.

2. Incomplete/incorrect documentation: There are defined formats for assessing patients clinically and functionally. Most of the time these forms and formats, which could give us important information are perceived too cumbersome to fill and many columns are left blank thus not allowing a correct clinical picture to be arrived at.These forms and formats are looked upon merely as documentation requirements for accreditation and nothing more. Let me share an example. An incompletely-filled fall risk assessment would not identify the patient at risk to fall although he would be at risk, the result being a patient fall in the hospital leading to harm. Many a times, the social and psychological assessments are ticked ‘not applicable’ and this results in failing to identify a patient who could be severely depressed and at a risk to harm himself/ herself.

3. it’s the ‘Quality Departments’ job’ syndrome: The pilot’s checklist, which has been used for decades is the main reason the risk of harm in aviation is 1:1,000,000. Each step in the process is done, checked and then ticked in the checklist prior to moving to the next step. We have been using checklists in the healthcare industry for some time now but still there is a 1:300 chance of a patient being harmed. Many times checklists are filled up at the end of the process as they are viewed as some data requirement for the quality department rather than steps originally created put to prevent errors and ensure patient safety.

4. Failure to recognise system issues: Healthcare delivery is a complex system since there are human and system components involved that requires proper co-ordination. A successful process is a combination of human and system elements, the human element being just a small part of the process. Whenever an adverse event happens, our first reaction is to identify the individual responsible for the lapse, blame them, name them and shame them. We send them for additional training or just terminate them since this seems to be an easier and more cost effective course of action. We fail to realise that the system has failed and needs to be relooked at. We don’t need fail safe systems. We need fault tolerant systems. In such a system errors are more difficult to commit and more easily detected/ corrected.

5. Staff issues: Many times we hear organisation and departmental leaders saying that they would require more staff if defined protocols need to be adhered to. It doesn’t matter how many resources you have, if you don’t know how to use them effectively no amount of hiring will ever be enough. Not having resources should never be used as a justification to cause patient harm.

6. Leadership commitment: For me personally, this is the most important factor. When protocols are broken and the people involved are important stakeholders the leadership is always in two minds. Act immediately or just look the other way since those breaking the protocols are top revenue grossers. There are organisations where the leadership places immense importance on following protocol and firmly spells out their position and there are also organisations where issues are swept under the carpet.

Which hospital do you think would have a safer system in place?

The choice is ours, implementing safe and sound systems does come at a cost; there is an increased cost to maintain quality, more work involved in putting systems in place and also the risk of ruffling a few feathers in the initial stages. But if we just pause for a second and look at it from a patient’s perspective, this is a small price that the healthcare industry should pay to ensure every patient’s safety during their stay in the hospital.


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