KEY POINTS:
What do patients want? Safer hospitals through system redesign. And what do patients want after they suffer a hospital adverse event?
We know from the work of Rae Lamb of the Health and Disability Commissioner's office that patients want acknowledgement that something did go wrong, an explanation, and
an apology. This is "open disclosure" and the national Quality Improvement Committee is looking at how to train healthcare professionals to meet this need.
Patients also want an undertaking that the same thing will not happen to other patients. This remarkable generosity of spirit is the impetus for the committee's body of work on making our hospitals safer, including co-ordinating the release of District Health Board sentinel events.
Adverse events - when efforts to help a patient actually cause them unintended harm - occur in approximately 6.3 per cent of hospital admissions. Many of these are not preventable. Thankfully most are mild and fleeting. But in a very small percentage of cases patients suffer serious harm (sentinel events).
There are a number of problems with how the data is collected - there is no agreed definition of sentinel events. Each health board has a different system to collect such events, and there is no national reporting structure. The committee's concern was that in an attempt to use this flawed data to construct a league table of "killer hospitals" (the term coined by Act's Heather Roy) this would lead to nonsensical comparisons, reduce public confidence and not prevent future patients from suffering harm.
Furthermore, there was concern that individual patients and their carers might be named and in the case of the carers, blamed. Blaming individual healthcare workers when things go wrong is a natural if misguided approach.
It is misguided for three good reasons: First, healthcare is a complex, team-based activity and it is rare that just one individual is responsible when something goes wrong.
Secondly, blaming individuals is counterproductive to building safer healthcare systems - it decreases the likelihood of future incidents being reported.
Thirdly, blaming individuals does not put pressure on healthcare organisations to examine how they deliver care, what defences they have in place, how they anticipate errors and mitigate the chance of harm. This is what we call the system of care, and good high-risk organisations do all of these things.
If a nurse or doctor makes an error and is disciplined or removed, the risk situation which allowed their "human error" to translate into harm to a patient remains, and another "human" will likely make the same mistake. If we suspended every healthcare worker who makes an error today, the error rate tomorrow would be exactly the same.
Here's an example of what I mean. In Britain over the past 15 years, 13 different doctors have made exactly the same mistake. They have confused two chemotherapy agents - methotrexate (injected into the spinal space) and vincristine (injected into a vein) - and have mistakenly injected the vincristine into the spinal space. Unfortunately, it is toxic to nerves and almost all the patients have died. You can be sure that in each case the doctor was censured, most would have blamed themselves and several will have left the profession.
You might think that this is good, they should be accountable. However, it has not stopped the error being repeated. This is what is termed a systems error - if well-motivated health professionals keep making the same mistake, then we need to look beyond the individual and redesign the system of care.
(In this case, delivering vincristine in a 100ml bag of normal saline already for insertion into the vein and therefore visually very different to the syringe of methotrexate).
If we are asking health professionals to be open about errors, then as a community we must not hamper this by misguided notions of individual accountability and blame. We need to accept that human error is inevitable and design around that fact - that is why cars have air bags.
New Zealand, like other countries, has to do better. Being open when things go wrong is a good start. The committee has co-ordinated the release of the sentinel events report to ensure that the focus is on the systems that contributed to them and to encourage a reasoned conversation about patient safety.
* Dr Mary Seddon is clinical director of the Quality Improvement Unit/Te Pai Huanga, Counties Manukau District Health Board.
