March 12th – 18th marked Patient Safety Awareness Week. The World Health Organisation (WHO) estimates that the occurrence of adverse events due to unsafe care is likely one of the 10 leading causes of death and disability in the world (1). In high-income countries it is estimated that one in every 10 patients is harmed while receiving hospital care, and around 50% of these may be preventable. The impact is even greater in low and middle-income countries, with two thirds of all adverse events resulting from unsafe care occur in low and middle-income countries (LMICs) (1).
What is patient safety?
Patient safety can be defined as ‘the avoidance of unintended or unexpected harm to people during the provision of health care’ (2). It has evolved as a discipline as complexity in health care systems has increased. A key concept is continuous improvement based on learning from errors and adverse events (1).
How do adverse events occur?
Spiritual needs should be provided if wished for. According to the family’s mind set, culture or religious background, this may involve providing support for their beliefs and values and helping them find meaning and purpose in the face of illness and death.
Some common patient safety issues are illustrated below:
||A leading cause of injury and avoidable harm; globally cost estimated at US $ 42 billion per year
||Occur in 7/100 and 10/100 hospitalised patients and high- and low-middle income countries respectively
||Around 7 million surgical patients suffer significant complications annually – some will be preventable
||Risk transmitting blood borne viruses e.g. HIV and hepatitis; burden of harm estimated at 9.2 million years of life lost to disability and death worldwide
||Occur in 5% of adults in outpatient settings; around 50% have potential to cause significant harm
|Unsafe transfusion practices
||Expose patients to risk of adverse reactions and infection
||Overexposure to radiation or wrong-patient or wrong-site identification.
|Lack of recognition of sepsis
||Sepsis affects around 31 million people with 5 million deaths per year worldwide
|Venous thromboembolism (VTE) prevention
||VTE accounts for 1/3rd of the complications attributed to hospitalisation
Table 1: common patient safety issues and impacts (1)
Most medical adverse events are not the result of a single action or event. Reason described a theory of active and latent failures, proposing that accidents within most complex systems including healthcare systems, are caused by a breakdown or absence of safety barriers across 4 levels (3). He describes these as organisational influences, supervisory factors, preconditions for unsafe acts (latent failures) and unsafe acts (active failures) (3). Some examples are shown below.
Organisation culture, values and beliefs, willingness of an organisation to openly learn and communicate
Organisational processes – strategic planning, policies, procedures, corporate oversight
Resource management – support from senior leadership to accomplish and support the above, allocation of human, equipment and monetary resources
Oversight and management of personnel and resources
Training, guidance and engagement
Planned operations – management and assignment of work, risk management, work tempo, scheduling
Failure to correct a known problem – when deficiencies in the team, individuals, equipment or environmental hazards are known to the supervisor but allowed to continue
Disregard for rules, regulations, instructions
Preconditions for unsafe acts
Environmental factors – tools and technologies, physical environment
Individual factors – mental and physical fitness for work
Team factors – communication, coordination (interrelationship between team members), leadership
Decision errors – goal directed behaviour proceeds as intended yet plan is inappropriate for the situation. Typically from a lack of information, knowledge or experience
Skill based errors – attention or memory failures, or errors associated with the practical performance of tasks
Perceptual errors – occur during tasks relying heavily on sensory information which is obscured or ambiguous
Routine violations – ‘bending the rules’, often habitual, encouraged by others and tolerated by supervisor and managers
Exceptional violations – isolated deparutres from authority, not typical of the individual nor tolerated by management
Table 2. Theory of latent and active failures (3)
This model is also referred to as the ‘Swiss cheese model’ – with the holes in the cheese depicting the failure or absence of safety barriers within a system (3). Most patient harm events are associated with multiple active and latent failures, although not every hole in a system will lead to an adverse event (3). An example could be a prescribing error – a doctor is prescribing medication in the middle of a busy ward. The active failure and unsafe act is a perceptual error – they are overloaded by noise and distraction and are unable to concentrate. The latent failures may involve preconditions for unsafe acts, including environmental factors (noise and distraction), task complexity and any number of team or individual factors, supervisory factors including training, risk management and failure to correct known problems, and organisational influences, including monetary resources to provide staff with enough computers and office space, cultural values and support from senior leadership. The risk of an error occurring is higher when these factors all come together (3).
Medical errors can also be grouped into errors of omission – for example not strapping a patient into a chair – or errors of commission, where the wrong action is taken, for example administering the wrong medication (4).
Other terminology often used includes:
- Near miss – an event that could have had adverse patient consequences but did not, potential adverse events that could have caused harm but did not (either by chance or due to intervention). These provide the same opportunities for learning as adverse events, and should also be scrutinised (4)
- Never events – events which should never have happened. Examples include wrong site surgery (4)
Human factors (HF) concerns the factors affecting our own performance and how we interact with others, teams and technology. Fatigue is a key factor, well recognised by the aviation industry, with strict limits on pilots’ hours. Fatigue affects decision making, situational analysis and awareness. Pausing to confirm a clinical decision can be key in preventing an error (5). Hydration, nutrition and recovery are important. A 1 -2 kg loss of body water through perspiration which is not replaced by drinking can cause a 15-20% reduction in cognitive function (5). Healthcare professionals’ environments may make a balanced diet difficult, with only 12% of surveyed UK NHS staff feeling that the NHS supported this due to a lack of health food options in the workplace (5). Healthcare professionals often skip breaks – preplanning short breaks into clinics or operating lists can be a solution. Emotions and stress also impact.
Communication and team work is key; verbalising instructions and using closed-loop communication can help (5).
What can we do?
As healthcare professionals, we can critically examine the environments we work in. Are there organisational factors that we can influence, is there a known problem within the environment that is being ignored, what is our working environment like, should we lobby for a prescribing corner, is there a habitual ‘bending of the rules’ that can be addressed? Are medications with similar names stored next to each other?
We can learn from errors that do occur, and from near misses. Near misses should be given as much attention as adverse events. Healthcare systems will have their own ways of examining errors, such as ‘datix’ or ‘incident report’ systems. These can be completed by any member of the healthcare team. A root cause analysis (RCA) is an investigative tool used to understand why an incident has occurred, and will be applied to incidents as needed. There are a number of different templates you can use (6). Models for change such as the Plan, Do, Study, Act (PDSA) cycle can be used (7).
We can be aware of and address human factors that influence our own performance and our ability to work with others (5). A team brief at the start of the day and a debrief at the end can bring the team together. The anacronym HALT is useful – stop if possible if Hungry, Angry, Late (or lonely) or Tired (5). Tools such as SBAR (Situation, Background, Assessment and Recommendation) can be used to streamline communication at key points in the day like handovers (7).
We all have a responsibility to take action to improve patient safety. The Institute for Healthcare Improvement (IHI) has lots of useful resources available this Patient Safety Awareness Week (7).
- World Health Organisation (WHO) Patient Safety (who.int)
- NHS England NHS England » Patient safety
- Wiegmann DA, Wood LJ, Cohen TN, Shappell SA. Understanding the “Swiss Cheese Model” and Its Application to Patient Safety. J Patient Saf. 2022 Mar 1;18(2):119-123. doi: 10.1097/PTS.0000000000000810. PMID: 33852542; PMCID: PMC8514562.
- Rodziewicz TL, Houseman B, Hipskind JE. Medical Error Reduction and Prevention. 2022 Dec 4. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 29763131.
- Brennan, P.A. and Oeppen, R.S. (2022), The role of human factors in improving patient safety. Trends Urology & Men Health, 13: 30-33. https://doi.org/10.1002/tre.858
- Card AJ, The problem with ‘5 whys’, BMJ Quality & Safety 2017;26:671-677.
- Institute for Healthcare Improvement Patient Safety Essentials Toolkit | IHI – Institute for Healthcare Improvement
About the authors:
Young EAP Representative for Advocacy
Sian is a member of the Royal College of Paediatrics and Child Health (RCPCH) Trainees’ Committee and currently works as a third-year resident at the Health Education North East in the UK. In her new role, she looks forward to representing trainees’ views on issues related to child health across Europe, raise awareness of current issues and promote this within paediatric training, as well as to advocate for children’s rights to health.