Imagine having your leg amputated without anaesthetic in an operating theatre where the surgeon came to the task with blood from his last operation caked on his hands. Or delivering your child in a Vienna hospital in 1847 before Hungarian physician Ignaz Semmelweiss decided that doctors were spreading childbed fever. He started forcing doctors under his supervision to wash their hands before touching patients. Consider those stories about hapless patients losing the wrong limb at surgery, waking to find their healthy breast or kidney removed, falling out of their hospital bed in confusion at night and breaking a hip or suffering a fatal brain haemorrhage, or being given the wrong drug, the wrong dose, or the wrong combination of drugs.
How safe are our hospitals now?
Just what is the story these days about hospital safety? Clearly the ghastliness of the days of bleeding people in pursuit of a cure (pacé Abraham Lincoln), or filthy conditions in wards or operating theatres, have passed – at least in the affluent one-sixth of the world that we Westerners inhabit. Still, records show that tens of thousands of people admitted to hospital in Australia each year suffer a misadventure – something goes wrong that is not necessarily consequent upon their illness or trauma, many are seriously injured, and some die. A review of the medical records of over 14,000 admissions to 28 hospitals in New South Wales and South Australia ten years ago revealed that 16.6% of these admissions were associated with an ‘adverse event’, which resulted in disability or a longer hospital stay for the patient and was caused by health care mismanagement. 51% of the adverse events were considered preventable. In 77.1% the disability had resolved within 12 months, but in 13.7% the disability was permanent and in 4.9%, the patient died (‘The Quality in Australian Health Care Study’. Med J Aust. 1995;163(9):458-71). Australia-wide, the estimate was 18,000 deaths and more than 235,000 thousand serious incidents each year.
No one expects hospitals to be safe havens. Patients with immune systems shot to pieces by chemotherapy for cancer or HIV are at high risk of infection; those admitted without clear personal identification are in no position to inform carers about drug allergies or serious existing medical conditions.
Even allowing for all these predisposing factors, the record of our health service in relation to safety has rocked politicians and frightened health service managers in the past decade. In response, they have established commissions at state and national level. The immediate questions are: How well are we travelling? Are we making progress? Is the number of calamitous or damaging and expensive errors decreasing?
Why are hospitals not safe?
First, to err is human: doctors and nurses, working under pressure are prone to error. This is especially so if they are tired, senior supervisory capacity is absent and the practitioners are inexperienced. Then a sizeable human factor operates. But, as one report from the US has it, while to err is human, to keep making the same mistake is utterly unacceptable
Second, Australia’s public hospital system stands at serious risk because recent management practices have centralized decision-making in paralysing ways, together with state and commonwealth pressure on funds. As Canadian social commentator John Ralston Saul has suggested, governments misguidedly or even unconsciously committed to greater efficiency through corporatism, rationalism and cutting can make beliefs such as ‘publicly funded health services cannot cope’ come true. They achieve this by not investing enough in them.
Starved of resources things will go wrong – from understaffed Accident and Emergency Departments through to geriatric services where the simplest elements of community nursing and physiotherapy cannot be provided. Fail to install bath rails in the home of a frail woman of 90 after discharge from hospital with a mild stroke and you can guarantee she will back before long with a broken hip. This ‘accident’ may occur in her home, but it is as certain a derivative of a starved health service as giving the wrong drug at night to a 70-year-old man in hospital with heart failure. Often, when you speak to clinicians, they know about these problems. Too often, they feel powerless to do a thing about them.
Resources are often wasted in health care. The Australian National Institute for Clinical Studies (‘NICS’) recently published a second report on evidence-practice gaps. The gaps in question exist between what we know to be good practice and what we do. In making its recommendations, the report uses two strategies that we know are important in translating theory into practice – first, expressing the theory in accessible language and format, and second, taking account of the social context of practice.
Third, we linger in a dark age of information. Both of us are engaged in limited clinical practice and have been for 30 years. We find the medical record system little changed since we were both interns at Sydney’s Royal North Shore Hospital in the early 1970s. With a paper-based system, it is overwhelmingly difficult to keep track of quality of care and to detect incidents that call for changes in the way care is organized. The electronic revolution has yet to transform the way we collect and hold medical information.
So what are we doing to achieve greater safety?
In the decade since the publication of the study that documented problems in the safety of hospital care in Australia there has been much activity. The National Council for Quality and Safety in Health Care has developed standards for giving open disclosure to patients and their families when things go wrong; for awarding credentials and defining the scope of practice of medical practitioners; and for avoiding wrong site or wrong patient surgery. We also now have a National Centre for Research Excellence in Patient Safety, a widely distributed booklet with tips on how to obtain safer health care for patients and the community generally, and a national program to prevent the faulty administration of drugs.
States and territories have developed peak safety advisory bodies and many elements of patient safety programs (e.g., the reporting and investigation of serious incidents) have been incorporated into hospital practice. Professional bodies such as the Royal Australasian College of Physicians have strengthened the maintenance of their members’ professional standards, and hospitals and other healthcare facilities have formed committees and created departments to oversee patient safety activities. Many hospitals have put in place mechanisms for staff to report incidents and near misses. One consequence has been a dramatic increase in reports. One drawback with investment to date has been its top down emphasis. Policies promulgated from the top do not always gain traction where the work is done.
Is it working?
Do we know whether patient care is safer as result? No. The national study of hospital safety has not been repeated. This is not to say that what we have done is useless; rather we do not know what it has achieved.
What can we suggest to improve safety?
First, we must develop standards for high quality, safe medical and surgical care. Studies have repeatedly shown that care for the patients with the same conditions varies greatly among individual doctors, geographic areas, and health facilities. Other complex industries, such as airlines and nuclear power plants, have standardised complex procedures to reduce the risk of things going wrong. The complexity of human health and illness means that solutions that work for machines will not work for patients, but general standards and best-evidence pathways reduce the wild fluctuations in patterns of medical and surgical care.
Second, we need more measurement. Each standard should have attached to it a measure that enables assessment of whether clinical practice is meeting the standard. The study which first alerted us to the tens of thousands of lapses of safety each year in Australian hospitals must be repeated, say every five years. In addition, all healthcare facilities and practices should be required to collect minimum information, in electronic form, on the quality and safety of their services.
Third, while defining standards and setting monitoring and measurement in place, we need to attend to the need experienced by medical teams for additional skill to ensure that everything that can be learned from error is learned. For this to occur cultures of blame and punishment should yield to management pressure to ones where learning – rather than point scoring and changing; rigidifying and defending – becomes respected behaviours. To achieve this change in current culture and practice, medical and other health professional education must shift gear. Educators are working to introduce curricula designed to teach the skills and support the necessary attitudes.
Fourth, at present there are few external rewards for safe practice. Karen Davis, of the Commonwealth Fund in New York and a respected commentator on health care, has argued recently that payments to hospitals for care through US Medicare should contain incentives for safe practice. As medical error is attributed to system problems, beyond the power of most doctors to influence, Davis’ suggestions address those who have the power to change the system – managers and administrators.
We should link hospital accreditation to demonstration of adherence to standards for safe care. Hospitals would be required to show that they could meet national standards, put the standards into practice and assess the results of doing so. The Commonwealth-State/Territory Health Care Agreements that determine levels of health service funding for five years could have financial incentives for greater safety built into them.
A recent review of the Australian Council for Safety and Quality in Health Care recommends its elevation to the level of a commission that reports to the Australian Health Ministers’ Council. The commission would lead and coordinate national initiatives in safety and quality; report publicly on safety and quality against standards; and recommend nationally agreed standards. No more important function for a national commission exists than establishing a national monitoring system so that we can track what is happening with hospital safety. It is a national disgrace that we do not have it.