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Concordia News - Patient Safety Culture - September 2009

Published by Hamish Brown

What's next for Patient Safety?

Five years after the IOM ‘To Err is Human' report,  the patient safety science, tools and knowledge have advanced rapidly.  But The Commonwealth Fund reports, "As difficult as the process has been, it has been the ‘easy' phase".

Case Studies demonstrate the critical importance of a safety ‘culture' in making patients safer. Developing and maintaining a safe culture is the ‘hard' phase because it deals with beleifs, values behaviours and traditional ways of doing things.

In the report, Paul Schyve, M.D.  and senior vice president of the Joint Commission on Accreditation of Healthcare Organisations, says "A culture of safety demands much of us; changes in our beliefs, values and behaviours. But we will be unable to fulfull our obligation to ‘first do no harm' to our patients unless we meet the challenge".

A copy of the report is available by email.

Self-reported medical errors

 The recently published results of a study of 11,900 respondednts, from seven countries show self-reported medical errors ranging from 12 - 20%. Results from New Zealand show the rate of self-reported medical, medication or laboratory errors at 16%.

The report concludes that patient error is a commonly occuring problem from the perspective of patients, and that by actively identifying patient, provider, and system related risk factors for medical error, there is an opportunity for improvement.

Communication and Patient Safety

 'The greatest problem in communication is the illusion that it has been accomplished.' (George Bernard Shaw)

The data from over 600 international hospitals and 194,000 health employees clearly shows that the area with the biggest potential for improvement that affects patient safety is communication. Especially during shift changes, hand overs and patient transitions.

The following table shows data from international hospitals compared to responses from  > 1,500 NZ employees

Some ideas and tips and for improving Communication

1. People at every level must be committed to the free and unobstructed flow of information up and down within your organisation.
2. Reward the courage to question assumptions, and the willingness to ask even seemingly obvious questions, to listen actively, and readiness to learn.
3. Build a ‘Value' for shared inquiry that is unimpeded by concern about ‘looking bad'.
4. Encourage being able to disagree vigorously and profitably, and engage in productive dialogue, where clarifying, understanding, and illuminating the issue at stake takes precedence over all other considerations for all parties.
5. Engage staff in patient safety aspects of challenging traditional ways of doing things, and uncovering new and better ways.
6. Open and clear communication means that people feel free from intimidation or retribution in raising issues, and are encouraged to ask questions or raise issues rather that feeling that expressing different points of views is risky.

Inspiration for improving patient outcomes is not about doing more of the same -

Not many great ideas come from sitting behind a desk, nor do they originate from repeating the obvious. The "We need: more resources... less waiting time in our clinic... more 'compliant' patients... more time... less paper work..." will never be the catalyst for change. Henry Ford once famously remarked: "If I had asked people what they wanted, they would have said faster horses."

On the other side of the planet French novelist Marcel Proust said, "The real act of discovery consists not in finding new lands but in seeing with new eyes." So if you want to find untapped innovation opportunities, look at the world around you with fresh eyes. Help others strive for a sense of ‘Vuja De' and prepare yourself for the creative ideas that follow.

...and finally

As of writing, there are only 95 days, 10 hours, 7 minutes and 46 seconds till Christmas!

Hamish Brown