Patient Safety R Us

Patients want to feel safe in the healthcare system. More than that, we need to be safe. We've all heard the horror stories: a medication error like the high dose of Heparin given to preemie twins that thinned their blood to the consistency of water; the sponge left in the patient, the wrong leg amputated, or post-operative complications that go unnoticed until it's too late. This is scary stuff, but how common is it that something goes wrong? I attended the second annual Interdisciplinary Conference, “Ensuring Patient Safety with Citizen Engagement,” held September 19-20 in Saskatoon to find out.

This innovative conference is the first to bring together the concepts of 'interdisciplinary', 'citizen engagement' and 'patient safety'. Physicians, nurses, pharmacists and the public together took a hard look at the difficult and complex challenges to patient safety. Sponsored by the Saskatchewan (SK) College of Pharmacists, SK Registered Nurses Association, and the College of Physicians and Surgeons of SK, the conference began with an open “Town Hall” session. The panel, “Your Health, Your Voice – Make it Count,” was moderated by Andre Picard, Globe and Mail health reporter. The four panel members related the multiple errors and omissions in care that resulted in horrific experiences for patients and their families, and the unnecessary deaths of loved ones. The place was packed. The conference – and the subject matter - was considered so important that a Legislative Assistant to the Minister of Health, the Opposition Health Critic, the head of the SK Union of Nurses, the Board Chair of the Health Quality Council, and others, spoke from the floor.

The study of patient safety is more than just a catalogue of errors and omissions. It is a full-blown area of study and research receiving increasing emphasis in Europe, Australia, the US and Canada. Organizations, research projects, and websites dedicated to patient safety have proliferated. Numerous strategies have been developed to identify gaps and problems with the aim of educating staff in health care settings to create a culture of patient safety and prevent the adverse events and near misses from occurring in the first place. But one of the most effective, direct – and unfortunately, least utilized - methods of determining the problems that must be overcome is to listen to the stories of patients and family members, and to pay attention to what is said by them when the patient is in care. Communication breakdown has been identified as a major problem.

Canada has a good, mostly efficient and, compared with most other countries, very cost effective health care system that provides a range of care and has some of the top professionals in the world. It requires constant updating to keep up with the knowledge and innovations resulting from medical research of all kinds. So if we know so much and have such a good system why are there adverse events and near misses that challenge our health and safety? It's a good question and the answer has a great deal to do with customer service. As Andre Picard said, the healthcare system doesn't walk the talk of patient centered care when the 'front door' of the system is too often the Emergency Room.

Did you know that the average length of time before your doctor interrupts you is 26 seconds? That the hospital is one of the least friendly, hardest to navigate and most inhospitable places on earth? That the 'culture' of health care gives precedence to 'the system' over the patient, and patients are viewed as 'cost centric'? Did you know that 'privacy' is often the reason given for not providing information? That 1 in13 patients suffers an adverse event in an acute care setting and a significant number are due to inattention? That adverse events are a leading cause of death – more than from lung cancer – and that most are avoidable? That 1 in 9 hospital patients contracts an infection, and 1 in 9 receives the wrong medication? That 5 to 25% of all hospitalizations are due to drug related adverse events? Patient safety is the business of patients as much as of healthcare professionals. It's in our interests to be proactive, but what can we do? Become an engaged patient:

Bring a baggie containing all medications – including vitamins, natural and over the counter products - to your health appointments, or carry an accurate list.

Comply with the treatment that you and your physician have decided is most appropriate for you. Report any unexpected reactions promptly.

Know the names of the drugs you take, what they are for and what they look like. Before you leave the pharmacy with any prescription or renewal always check to see that the medication is the correct one, with the correct dosage. Make sure that each of the medical professionals you see for care is aware of all the others you see.

Find out why a test or treatment is needed and how it can help you. Make sure you know what is involved and what to expect. Keep a medical journal of your treatments and care, including medications, and tests. If you are leaving hospital make sure you have written directions about treatment plans and instructions, and know who to call if there are problems.

Ask questions, ask questions, ask questions. Never be afraid to ask questions. Speak up! Help prevent errors in your care. An engaged patient is a safer patient!

Check out these excellent websites:

Patient Safety-Health Canada http://www.hc-sc.gc.ca/hcs-sss/qual/patient_securit/index-eng.php

Canadian Patient Safety Institute http://www.patientsafetyinstitute.ca/index.html

Canadian Patient Safety Week is September 29 – October 4.

My thanks to Best Medicines Coalition for sponsoring my conference registration. AMD