Medical Errors: Prevention is Possible

By Joe Kiani, Founder and Chairman of the Patient Safety Movement Foundation

To err is human, as the Institute of Medicine report stated in 1999, but to not put in place processes that can prevent human errors from becoming fatal is inhumane. Together that’s what we need to do. Hospitals need to implement known processes, of which there are more than 30, to avoid killing nearly five million people every year, in our hospitals globally.What if you had the opportunity to save a life? The life of a loved one, a close friend, or even a stranger?

What if I told you it’s possible to reach zero preventable deaths in hospitals by 2020 by simply making a commitment to zero and implementing actionable patient safety processes? By making a public commitment to zero, implementing a patient safety focused culture, or even sharing your actions and patient safety processes, you could save not just one life, but thousands.

What if I told you the only way to stop preventable patient hospital deaths, the 14th leading cause of death around the world, is if you made patient safety your personal responsibility? The latest estimate is that over 4.8 million people are dying annually; that equates to over 13,000 people dying each day; that’s 45 fully loaded 787’s crashing every day and killing all of its passengers!

According to Dr. Tedros Ghebreyesus, the Director-General of the World Health Organization, “the reality is that every year, millions of patients die or are injured because of unsafe and poor-quality healthcare. Adverse events are now estimated to be the 14th leading cause of death and injury globally. That puts patient harm in the same league as tuberculosis and malaria. There are an estimated 421 million hospitalisations in the world every year, and on average, one in 10 of those results in adverse events. This is a frightening statistic. Especially when we know that at least half of adverse events could be prevented.”

So, what can we do to prevent medical errors and preventable patient deaths in hospitals?

First, join us in our fight. Our mission at the Patient Safety Movement Foundation is to eliminate preventable deaths in hospitals by 2020. We are an action-oriented organisation. We are proactively collecting commitments from hospital systems, open data pledges from healthcare technology companies, and ‘Commitment to Action’ letters from key associations, professional organisations, advocacy groups, and non-profits who are also working day in and day out to improve patient safety. We are growing stronger and closer to reaching zero preventable deaths each year, together. I urge you to join us and make a commitment to improve patient safety. It’s free. 

Second, take action. Research shows that evidence-based processes can be put into place, which prevents medical error and reduces preventable harm. Since I launched the Patient Safety Movement Foundation in 2012, we have teamed up with some of the world’s leading medical experts, hospital administrators and patient advocates to share best practices and the latest evidence-based solutions to the leading causes of preventable harm in hospitals. Today, we have 31 Actionable Patient Safety Solutions (APSS) that cover the 16 leading causes of preventable patient death, which include hand hygiene, healthcare-associated infections and more. Close to 5,000 hospitals across 44 countries have implemented these APSS or their own novel solutions to reduce preventable mortality. Last year, between 81,533 and 200,000 lives were saved as a result of these hospitals’ patient safety efforts. 

We offer the APSS at no cost. They are free to download and are written in a checklist format to allow hospitals to audit their systems and identify areas for improvement. I encourage you to use them or any other evidence-based processes to protect patients and clinicians. The key is to implement processes and learn from them and improve them.

Third, implement a culture of safety and begin tracking cases of preventable harm. For the last six years, we have worked in concert with leading medical experts around the globe to identify the leading causes of preventable patient harm from handoff communications to delayed detection of sepsis. Remarkably, the leading cause of preventable patient deaths is when hospitals lack a culture of safety. In fact, a 2017 review of patient safety in the Arab countries identified that punitive response to error is seen as a serious issue, which needs to be improved. Healthcare professionals in the Arab countries tend to think that a ‘culture of blame’ still exists that prevents them from reporting incidents. 

Studies report that hospital departments where staff have more positive patient safety culture perceptions have fewer adverse events. So, what does a culture of safety look like? A strong safety culture promotes the identification and reduction of risk as well as the prevention of harm. A poorly defined and implemented culture of safety may often result in concealing errors and therefore a failure to learn from them. According to the Institute of Medicine, “the biggest challenge to moving toward a safer health system is changing the culture from one of blaming individuals for errors to one in which errors are treated not as personal failures, but as opportunities to improve the system and prevent harm.”

Hospitals like the United States’ Parrish Medical Center have seen dramatic improvements as a result of their culture of safety. The hospital is consistently rated “A” by the Leapfrog Group, #1 Safest Hospital by Florida Consumer Reports and won the first-ever five-star Hospital Ranking by the Patient Safety Movement Foundation. At Parrish Medical Center, they have put action behind their culture of safety by continuously tracking and monitoring cases preventable harm. As a result of their measuring and monitoring of preventable harm, they’ve dramatically reduced preventable harm. For example, they’ve achieved zero ventilator-related pneumonia in 12 years, one catheter-related UTI in 10 years and one central line-associated bloodstream infection (CLABSI) in the past ten years. 

Finally, start now and start somewhere! Hospitals are proving that zero is possible. We’re already seeing hospitals getting to zero deaths in certain areas such as healthcare-associated infections. For example, like Parrish Medical Center, Tri-City Medical Center in San Diego, California, recently celebrated seven years of zero central line-associated blood stream infections (CLABSIs) in its neonatal ICU. Intermountain Healthcare System based in Salt Lake City, Utah, hasn’t seen a single catheter-associated urinary tract infection in its 160-bed LDS in six months. The common thread is that these and other hospitals remarkable patient safety outcomes are putting systems in place to improve patient safety processes while creating a culture focused on what’s best for the patient. 

And the positive momentum is growing. On November 15, we partnered with the Dubai Healthcare City Authority for the first conference to present regionally-relevant patient safety initiatives and models from the UAE’s health sector. The Dubai Healthcare City Best Practice Conference 2018 called on hospitals and clinics in the UAE to share their applied patient safety best practices to help advance a culture of safety. The conference drove DHCA’s commitment to bring the Patient Safety Movement to the Middle East and reduce the number of preventable deaths in hospitals to zero by 2020. 

The conference had three categories – Infection Control and Medication Management; Advancing a Culture of Safety; and, Enhancing a Positive Environment of Care. These categories have been identified as some of the leading patient safety challenges facing hospitals today. DHCA was the first group in the Middle East to make a public commitment through the PSMF to improve their culture of safety. By gathering to focus on patient safety and share best practices at this conference, they set an example for the world that reaching ZERO is possible.For details, log on to https://www.dhcr.gov.ae/en/DHCC-Best-Practice-Conference

Zero preventable patient deaths is possible, but it is up to you, not the person on your right or your left, but you. Act now!