‘To Err is Human’-Patient Safety
“Prescribe regimes for the good of my patients according to my ability and my judgment and never do harm to anyone” so goes the hippocratic oath that medical professionals take. Patients come to hospitals to get well and not get more unwell! Institute of Medicine, USA in 1999 reported that 44,000 to 98,000 preventable deaths annually is due to medical error in hospitals and all these can happen even when medical professionals have best of the intentions and follow the best drawn out protocol.
From my own experience, I went for blood test, the lab/diagnostic service center is very well known for its quality. The lab had proudly displayed ‘NABL’ Certificate on the wall. The young technician drawing blood did not change the gloves she had used for the previous patient. When I reminded her gently, she said ‘I will wear a new pair, if you want’. It is not what patient wants but what ‘the correct protocol’ is. By not changing gloves after each test/drawing blood, I noted that she was protecting herself but not protecting me-the patient. A couple of hours later, again she did not change gloves for drawing blood from another patient.
Many of the incidents of lack of patient safety and medical errors are generally known through media reports and medico-legal cases reported. A survey covering 25 large-and medium-size hospitals by Acme Consultants reported that only 32% of hospitals in Bengaluru have put adequate patient-safety measures like grab bars in toilets and free exit routes.The audit also examined factors like waiting time, nurses’ skills, hygiene factors, ethical issues, doctors’ communication skills, parking facilities, availability of all services under one roof and emergency services. However, this does not mean that we conclude “Hospitals in India are unsafe”. Most hospitals and medical professionals do provide good quality of care, however, all aspects of quality and patient safety measures are not formally adhered to in all cases. Some major hospitals are not only providing care comparable to any best hospitals in the world but also very successfully engaged in “Medical Tourism” in many specialty areas.
A very senior Physician of a well known large hospital of Bangalore, who is also a Quality Auditor for NABH and JCI informed that many of the hospitals she audited hardly reported about ‘illegible prescriptions’ and other adverse events, may be due to the fact that the Accreditation dictates that such reporting should also do a ‘root cause’ analysis, report and take actions to rectify. Even, incentivizing reporting among professionals did not show a big improvement over a period of time. And most in the meeting agreed that clinicians, nurses, hospital managers and related professionals are afraid of reporting errors and consequences of reporting.
‘To err may be human’ but ‘not reporting and changing/improving ways of doing things’ is not so human. It is not just the fear of legal action, many errors may not always qualify for ‘medical negligence’ but the take home message is about ‘reporting, documenting and continuously improvement’. No medical professional will disagree about the fact that “patient safety is of utmost importance”. In fact, physicians and nurses are committed to patients’ recovery and health is a key motivator for professionals. In the era of fast growing medical technology, team work, increased expectations and awareness of medical information (by patients and others) and access to information, hospitals are expected to perform better and better. To err is human, but change in mind set, culture, leadership and robust process improvements using lean, six sigma and change management for patient safety measures is the need of the hour.
The writer is Dr. Usha Manjunath, Dean-Academic and Student Affairs, Institute of Health Management Research (IHMR) Bengaluru.