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