Building the right culture is key for patient safety

This article is by Sheri Wilbanks. 

Medical errors are estimated to be the third leading cause of death in America, behind heart disease and cancer. As many as 440,000 people are dying each year from these mistakes which includes medication and diagnostic errors, surgical complications and a lack of follow-up on adverse lab results.

While there is no published data on Asia, the region has seen a rise of patient safety incidents recently. Just last year in Hong Kong, a part of a man’s lung was removed after his contaminated tissue sample was misdiagnosed as being cancerous. In Singapore, an outbreak of hepatitis C due to poor infection control at a local hospital caused seven deaths.

These incidents demonstrate the profound impact medical errors can have on patient safety. While a healthcare organisation will never be able to completely rule out human error, there are measures that can be put in place to manage the risk.

Patient safety concerns in Asia

Patient safety remains a top priority for every healthcare organisation, but knowing where to direct patient safety initiatives can be a daunting task. Identifying key patient safety concerns is the first step to creating a safer environment for patients.

At the Quality Forum for Healthcare and Safety in Hong Kong late last year, AIG conducted a survey polling Asian healthcare providers and patient safety specialists on their top patient safety concerns. The survey referenced the ECRI 2015’s top 10 list of patient safety items in the United States as a guiding framework.

The results revealed data integrity, inadequate patient handovers related to patient transfers and care coordination events related to inadequate medication reconciliation to be the top three patient safety concerns in this region.

Data integrity

Data integrity came up as the number one concern in the region and at a country level in Hong Kong. Data integrity errors occur as a result of incorrect or missing data in electronic health records (EHRs) and other health IT systems. This issue is becoming more prevalent as healthcare organisations and healthcare professionals increase their use of EHRs.

While electronic documentation tools provide improved efficiencies of data capture, timeliness, consistency and completeness, there are also risks in using EHRs. If not designed properly, implemented carefully and used thoughtfully, EHR technology can create new safety risks such as missing data, delayed data delivery, inaccurate or outdated clinical information and inconsistencies in patient information. These data errors can lead to a number of patient safety issues such as misdiagnosis, mistreatment or inaccurate medication prescribed to patients.

Inadequate patient handover related to patient transfer

As the survey results indicate, there has been a growing awareness that high quality handover practices are critical to ensure continuity of care and patient safety.

Safe patient handover involves identifying and providing appropriate resources for the patient during transport and implementing standardised handoff communications protocols to and from trained transporters. Inadequate patient handover can result in delays in diagnosis and treatments, redundant activities such as additional procedures and tests and unnecessarily long hospital stays – all of which increases the patient’s exposure to potential instability and medical risks.

Medication reconciliation

Medication reconciliation is the process of comparing a patient’s medication orders to all of the medications that he has been taking – an important step to ensure the patient is on the right medications for the next phase of care.

Inadequate reconciliation in handoffs during admission, transfer and discharge of patients can result in medical errors such as omission, duplication, incorrect doses or timing, and adverse drug-disease interactions. This puts the patient at risk for medication errors, inadequate follow-up care and hospital readmissions.

Building resilience for optimum patient safety

Identifying the top patient safety concerns in Asia is a good start to driving patient safety conversations in the healthcare environment, and for setting patient safety priorities.

To correct these concerns and build a more efficient patient safety system, healthcare organisations must first cultivate the right environment. There needs to be added emphasis placed on the system of care that prevents errors, learns from the errors that have occurred, and builds a culture of safety that involves all healthcare professionals and patients.

As a start, healthcare organisations must learn to move away from the “blame culture” – where individual staff are blamed and punished for errors, and instead focus on promoting a just culture. A just culture encourages open reporting of errors, focuses on determining the root of the problem, enables learning and stresses on teamwork to find and take the necessary corrective actions. By creating a culture like this, team members are enabled to take action when it is needed and staff members can report adverse events and unsafe practices without fear for reprisal.

Setting and maintaining a just culture requires commitment from the upper management. Leaders need to lead by example to create an environment where staff are comfortable to share information, openly discuss issues and disclose errors. This helps create a partnership where the leaders and all staff members share accountability for safety.

Healthcare organisations can also look outwards to industry experts to assess, review and validate their patient safety system and procedures. In working with their insurance partner for example, healthcare organisations can gain access to knowledge transfer and sharing on the risks and exposures that the insurance partner sees and manages in the industry every day.

As one of the world’s leading insurance companies, AIG has Asia Pacific-based healthcare experts with strong experience consulting on healthcare organisations and working with those organisations to improve their performance in the area of patient safety. This allows healthcare organisations to tap into our global expertise to ensure we are always implementing best practice, learning from the most recent patient safety cases and discussing means to improve on patient safety efficiencies.

The above article is an Oped piece by Sheri Wilbanks,  Head of Casualty Risk Consulting, AIG Asia Pacific. Sheri works with a team of professional consultants to assess healthcare organizations and work with those organizations to improve their performance in the area of patient safety.

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