Making improvements to healthcare safety

Those of us who work in health don’t leave home each morning thinking about what harm we are planning for that day, just the opposite. But healthcare is dangerous. The Quality in Australian Healthcare Study found that at least 8 percent of hospital admissions in Australia are associated with a reported adverse event which could have been prevented. And these were just the adverse events that were reported.

Reliable estimates suggest that 18,000 to 27,000 avoidable deaths occur annually, with an additional 50,000 patients suffering permanent injury. Quite apart from these human tragedies, the costs to the health system in terms of extra time needed in hospital, drugs and equipment approximates $4 billion per year.

It’s because multiple factors thwart our good intentions, including health care complexity; communication errors; poor organisational culture; reluctance to ask for help; emphasis on self-reliance; inadequate teamwork; drug errors and lack of involvement from the patient.

This problem is not unique to Australia.

Figures from other countries with well-developed healthcare systems all report avoidable adverse events ranging from 8 to 12 percent of hospital admissions.

Modern healthcare is complex.

Intricate equipment continues to evolve with little standardisation across wards and departments so that staff moving from one area to another may be expected to master multiple varying products. There are interruptions, distractions and urgency. The nature of the work has small margins of safety. There is incomplete knowledge about many diseases.

Errors of communication are a common problem too.

The airline industry has taught us that flattening the hierarchy makes it easier for a junior person to speak up if they detect a problem. We have only recently realised assertiveness training can help juniors to speak up in the patient’s best interests. We are learning the importance of communication techniques such as check-back, time out (e.g. correct patient, correct procedure, equipment available) before commencing a procedure, debriefing (problems we encountered, what went well, what we could do to improve) following a procedure and the value of listening as well as talking.

Blame culture keeps errors hidden.

Sadly, there are still areas in health where the culture is not conducive to safe care; places where mistakes are seen as opportunities for blame, for discipline, to make an example of the offender. This ignores the fact that in 80 percent of errors, the problems are with the system. It ignores the fact that a blame culture keeps errors hidden. In contrast, the increasing trend towards a more open health culture has shown that errors are opportunities to learn, to make things safer and that a relentless focus on recognising errors helps them be prevented in the future.

Healthcare is a team game.

The era of the omniscient doctor is over. Multidisciplinary team members learn from, respect and support each other. They have a common focus – achieving the best result for the patient. And the best teams have the patient as an integral part of the team. Patients are listened to and respected, given information that helps them make informed decisions about their care and their observations are valued, rather than dismissed.

While the dangers of healthcare must not be underestimated, good progress is being made. Bodies such as the Australian Commission on Quality and Safety in Healthcare, the Clinical Excellence Commission in NSW and its counterparts in other states are providing training, advice and monitoring data, all with a view to making healthcare safer. Safety and quality is now taught in most Australian medical schools.

We now know that error can be reduced by using checklists, rather than relying only on memory; improving communication and listening skills; working in teams; being able to ask for help when needed; standardising procedures and equipment and teaching the next generation of doctors to understand the causes of errors and how to reduce them.

Finally, but of major importance is the role of the patient. We need to encourage our patients not to be afraid to ask questions, particularly if they are worried or if something doesn’t seem right. If the doctor is communicating in jargon, they should know that it is alright to ask for a layperson’s explanation; that it is quite acceptable to ask, ‘What are my options?’, ‘What are the risks?’ and that if they are in any doubt, they have the right to ask for another opinion. In a safe healthcare system, every patient should be an equal partner in their own care.

About the author

Emeritus Professor Kim Oates AO MD DSc MHP FRACP FRCP FAFPHM was the University of Sydney’s Foundation Douglas Burrows Professor of Paediatrics and Child Health from 1985 to 1997, becoming Chief Executive of the Children’s Hospital at Westmead until 2006. Following this, the Clinical Excellence Commission asked him to develop and teach a patient safety program for medical students and young health leaders. He introduced this into five medical schools and founded the Australian Academy for Emerging Leaders in Patient Safety. He has received the Alumni Award for Community Service and was elected as one of the 30 founding members for the International Academy of Quality and Safety in Healthcare. With Professor Anne Sefton, he was also the founding editor of Radius.

With the introduction of the MD 2020 at Sydney Medical School, a number of new initiatives were introduced to improve safety culture throughout each year of the degree. For example, in year 1 students partake in introductory sessions to improve their teamwork and communication with other health professionals. These sessions expand into medication safety in year 2 and interprofessional mass trauma simulations in year 3. An e-Bootcamp workshop was also introduced in 2020 to prepare students for their NSW Health AiM (Assistants in Medicine), and to meet the needs of the COVID-19 pandemic response. This training has been invaluable preparation for students leading into their internship.