Learning together for safer patient care

[Music]

the

kobe 19 pandemic has brought healthcare

back into focus we’ve all begun to

realize

that we need to be investing more into

our health care in infrastructure

human resources r d as well as in

putting the right kind of systems in

place

i passed my mbbs in 2001

so i’ve been a doctor for nearly two

decades now

and i’ve spent almost half of that

period working in india

and the rest for the national health

services uk

what i’m going to share with you is

partly based on my own

observations and reflections but also on

more objective learning

and research when i was a kid

i used to watch a lot of old hindi

movies on doordarshan

and the typical doctor in those movies

would be a well-dressed middle-aged man

who would emerge out of the patient’s

room with a black suitcase

and declare

there’s nothing to worry about i’ve

given him an injection and he will be

fine by morning

i was quite fascinated by the character

i sometimes wonder whether it had a

subconscious

impact on my choice of profession

but when i finally did become a doctor

much to my disappointment i realize

but that magical injection did not exist

healthcare systems are far more complex

today

for example think of an operation

theater

or an intensive care unit think of all

the high-tech gadgets

people with varying skill sets

potentially toxic drugs being used

support from the diagnostic labs i.t

support

communication which could be verbal

written digital

all sorts and at the center of it all a

sick patient

things could go wrong at any level

errors could have cascading effect

with disastrous consequences

for example imagine that a tired nurse

or a doctor has been up all night puts

the wrong label

on a patch sample now for those of you

who

are not from a medical background cross

matching is the process of

testing whether the blood meant for

transfusion

is compatible with a patient’s own blood

so this could lead to a fatal

transfusion reaction

but are we imagining things

creating unnecessary paranoia or is this

real

well i have seen things going wrong on

so many occasions

and from both ends as a doctor as well

as in the case of my own relatives when

they’ve been

unwell and admitted but

going beyond personal experiences

there were two studies in 1997 in

america

the harvard medical practice study and

the

utan colorado medical practice study

that looked into

deaths occurring due to medical errors

and when they extrapolated their

findings for the entire country

they estimated the average number of

debts per

year due to medical errors to be 44 000

and 98 000 respectively

now even if we take the more

conservative of the two estimates to be

true

that’s equivalent of a jumbo jet

crashing every single day

now it doesn’t grab headlines it doesn’t

have the same kind of

impact on people’s minds because these

debts are scattered all over the country

initially these findings were met with a

lot of skepticism but subsequently

several studies have thrown up similar

figures

the problem was officially recognized

a few years later when the institute of

medicine came up with its report title

to ur is human building a safer health

system

since then patient safety has come to be

recognized as a major challenge

globally who came with its

patient safety program in 2004

and of the last few years we have seen

growing awareness even in india

but we have just quite begun our journey

towards a safer healthcare

building a safety culture in healthcare

organizations is paramount

now what do i mean by that suppose

i make a mistake or my colleague makes a

mistake and i happen to find it down

now if there is a risk of being

penalized or reprimanded

what am i likely to do i’ll probably try

to cover it up if it’s my own mistake

or just look the other way if it’s my

colleagues

but then as a team as an organization

and as medical fraternity will we ever

learn the right lessons

patience after patients will continue to

come to harm

as we will continue to make the same

mistakes over and over again

so we need to break this silence but not

by pointing fingers it’s important

to realize that errors happen not

because of

bad people in health care but because of

good people

in bad systems so we want to fix the

system

we have to create an environment of

openness where people don’t feel

threatened

they find it easy to admit their own

mistakes and to report

others

healthcare organizations must lead and

support their staff

in creating a culture of patient safety

there are two aspects of patient safety

risk assessment is a proactive process

where you foresee a risk

before an error actually takes place

so you see a loophole and plug it before

anything until it happens

so for example you could design a toilet

in a hospital in such a way that elderly

and frail people

don’t fall down and break their bones

but

there’s also a reactive component of

patient safety

when something goes wrong we need to

take steps to mitigate its effects

and to prevent its recurrence

and this is precisely what we mean by

learning from mistakes so how do we

institutionalize this

the answer is incident reporting

healthcare organizations must encourage

written reporting of all adverse events

and

near-miss events when something went

wrong but nobody actually came to any

harm

incidents must be reported and

investigated

i will give you an example

from my own experience where we not only

reported an

incident but also tried to implement a

solution

so on our wards we have these drug

charts where the doctor prescribes the

medicine

and the nurses sign against them when

they administer them

so we had this patient with an irregular

heart rhythm

and we prescribed her a blood thinning

medicine

called warfarin to cut down the chances

of getting is true

now warfarin is a double-edged sword

meaning that if we thin the blood down

too much

there is a risk of bleeding so

we need to monitor its effect on the

body by doing a blood test

called inr so

in the case of this patient when the ion

went

above 3 because we like to keep the

value usually between 2 and 3.

so we when it went above 3 we reduced

the dose

but in spite of successive dose

reductions

her inr kept going up so we withheld the

medicine

but to our surprise it still kept going

up and reached quite dangerous levels

so then we decided okay we’re done with

it we’re not going to give her any more

offering

and we’ve reversed the inr with vitamin

k which is

an antidote to warfarin

but we knew something was not right here

because what had happened

defied any logic so we decided to look

beyond the obvious and after a thorough

investigation we found out

that this lady had continued to take

warfarin in the original door

we needed to address this problem

communication errors

are actually one of the commonest

sources of medical errors so

after a discussion with the nursing team

we decided that we were going to paste a

notice by the side of each bed

saying that the patients should not take

any medicines on their own while they

are in the hospital

and that these would be administered by

the nurses under their direct

supervision

incident reporting is a standard

practice in most countries or in many

countries of the world

when i’ve spoken to my colleagues and

friends in india

they’ve all agreed in principle but some

of them have expressed concerns about

creating a written record of something

that could be used

against them legally i think this is a

genuine concern

but i think it’s still possible for

healthcare organizations to

work around this problem so for example

the incident reporting forms could be

made anonymous

furthermore once an incident has been

investigated and a report prepared

which should certainly not reveal any

identities

the original incident forms could be

destroyed

permanently as an organizational policy

so to summarize patient safety needs to

be

embedded in the culture of healthcare

organizations

it should be incorporated into the

training of doctors and nurses

from a very early stage and hospitals

must have a separate cell to look into

patient safety issues

they must create an environment of

openness

incidents must be reported and

investigated

lessons should be learned and shared

now so far i’ve only been talking about

what organizations need to do

but in the long run we need to look

beyond

organizational boundaries and forge a

partnership with the public at large

we need to convey to them that

creating an environment of openness is a

prerequisite for safe delivery of health

care

if doctors or other health care

professionals

are afraid of being sued or were still

physically assaulted

they will never admit their mistakes so

rather than

harassing healthcare workers

it’s important to put pressure on

healthcare organizations so that they

put

systems in place i’m really optimistic

that a time will come when

doctors and nurses will find the courage

that if something goes wrong they should

be able to go and tell the patient

as well as their relatives about what

has happened

what steps have been taken to minimize

harm and reassure them

that lessons will be learned and

implemented

not all errors are preventable but

certainly

with vigilance and constant efforts we

can minimize

their occurrences so

let us join hands today to create a

safer healthcare tomorrow

we shall overcome one day