I remember the day the Institute of Medicine (IOM) released its seminal 1999 report: To Err is Human. I was attending a quality improvement conference in the United States when the announcement was made. I thought it would change everything.
Major American news networks led with the story of this report and the large number of patient deaths related to medical errors in hospitals – possibly as many as 98,000 per year in the U.S. The demand to understand and address these errors reverberated from Congress to hospitals and from regulators to patients.
I, like many others, welcomed the IOM’s objective recognition that harm and death are avoidable in healthcare and embraced the call to action to go beyond blaming individuals.
The IOM had envisioned a healthcare system wherein providers, regulators, patients, families and others could work together to design care processes that prevented, recognized, and quickly recovered from medical errors. This would of course include using human factors science within a just and trusting culture.
Much has been done in Ontario and Canada since the release of the IOM report. The Canadian Adverse Events Study, released in 2004, focused on the care delivered across the country. The research team found that an estimated 7.5% of patients admitted to acute care hospitals in Canada experienced 1 or more Adverse Events (AEs), and 36.9% of these patients were judged to have highly preventable AEs. They extrapolated that 9,250 to 23,750 patients died from AEs that could have been prevented.
The study’s findings—as well as the passion of many individuals, organizations and governments across the country—have moved our healthcare system forward in so many ways.
Yet, I still meet and talk with many who are not aware of the breadth and depth of the issue or the need to go beyond relying primarily on the vigilance of individuals to prevent, recognize and quickly recover from errors in healthcare.
In some areas, there is also a fear of reprisals that can prevent transparent reporting of adverse events. Each time an adverse event goes unreported, it is a missed opportunity to learn, share and improve the applicable care process.
Do we really believe that To Err is Human?
Do we recognize that human error is inevitable and act accordingly? Whether you are an individual practitioner, a health organization, a community pharmacy, a regulator, a Ministry and/or other relevant organization, what steps have been taken individually or collectively to design a safer system for all?
The stories showcased on Quorum are examples of how hospitals are designing safer systems:
Also, at the recent Health Quality Transformation 2018 Conference, North York General Hospital was recognized for their poster Standardization of Prescriptions to Decrease Excess Opioids After Appendectomy and Cholecystectomy. Their work included a patient information sheet called Opioids for Pain After Day Surgery – Your Questions Answered.
It is inspiring to see these examples of where a small group of committed individuals are bringing professional accountability together with system changes to make it easier to do the right thing!
Additionally, I’m highlighting three possible areas for advancing patient safety to stimulate further discussion, sharing and learning.
Personal
- Take a moment to reflect on your own fatigue and distraction levels. Self-recognition and self-care strategies are essential to the safe delivery of care by all providers.
- In addition, individuals can develop their communication and collaboration skills as a contributing member of a high functioning team. Helping each other to do the right thing is now recognized as an essential part of saving lives, yet many providers still don’t have the resources and time to make this a reality with their teams.
Organizational
- Leaders at all levels of an organization can acknowledge, appreciate and learn from medication incident reports, then share learning within and externally. Nothing speaks louder than actions and “walking the talk” consistently will raise the safety culture to new levels.
System wide
- Everyone can recognize that no one cares more about safe medication use than patients and families. There are many ways to meaningfully engage them in designing and delivering medication processes.
- One example is patient access to their own electronic health records, including an up to date list of medications with details such as the doses/frequency, reason(s) for taking them, and any applicable comments.
We may not have fully implemented the system described almost twenty years ago in To Err is Human, but we’re on the journey.
Please share your comments and questions by clicking on “Add a Comment” below, or reach out to Carolyn Hoffman, President and CEO at the Institute For Safe Medication Practices Canada (ISMP Canada), on Quorum.
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