Making Care Safer for 'Our' Patients Collectively
Canadian Patient Safety Week
By Debbie Roberts, VP Quality and Performance, North Simcoe Muskoka Local Health Integration Network (NSM LHIN)
October 30, 2017
Debbie Roberts, VP Quality and Performance, NSM LHIN
Hearing the news earlier this summer that a jet narrowly missed landing on a crowded taxi-way got me thinking about safety in high-risk industries such as aviation, nuclear power and, of course, health care and the role that each of us can play in making care safer.
Health care is a complex industry and humans – both patients and providers – are critical components of the system. We know that humans are not infallible; they will make mistakes; things will go wrong. It is predictable and inevitable. And, the numbers are staggering.
During Canadian Patient Safety Week, October 30 through to November 3, I want to shine a light on patient safety as important to both those who deliver care and those who receive it.
In 2004, the Canadian Adverse Events Study reported that the rate of adverse events in Canadian acute care hospitals was approximately 7.5%, with an estimated 185,000 adverse events annually, and approximately one-third to one-half of them were preventable.
Home care does not fare any better. In 2013, the Canadian Patient Safety Institute, and others, published the first home care safety study, Safety at Home – A Pan-Canadian Home Care Safety Study. The annual rate of adverse events in home care was estimated to be 13% with 56% of them preventable; 7.5% resulted in the death of a patient.
Employees of the North Simcoe Muskoka Local Health Integration Network (NSM LHIN), as stewards of the health care system and health care providers, come to work every day wanting to do what is best for patients. In such a complex, human service industry, how can we make health care safer?
To a great extent, we know the high-risk areas in health care and we know the principle cause of errors: the interaction among people, tools and technology and the work environment. In short, the interaction among patients, their care providers and the “system.” Rarely does a catastrophic event result from the action or inaction of a single individual. Most commonly, they are caused from a cascade of smaller errors occurring within a complex system.
There is much that we can learn about improving systems from approaches used in other industries (such as aviation and nuclear power). This is particularly the case in the fields of ‘human factors engineering’ and ‘high reliability organizations.’
Human factors engineering focuses on how systems work in actual practice, with real, fallible human beings at the controls and attempts to design systems that optimize safety and minimize the risk of error. It uses tools and techniques such as usability testing, forcing functions (error-proofing) and standardization to minimize the potential for human error.
High reliability organization (HRO) is used to describe organizations in high-risk industries that operate with very low failure or defect rates over time. A key feature of HROs is their heightened sense of mindfulness, their preoccupation with failure and their focus on both prevention and containment of risks. They are not complacent or arrogant. Staff are constantly on the lookout for things that went, or almost went wrong. They have a very low threshold for initiating incident reviews and analyze each event to identify opportunities to improve the system. HROs recognize that even in the best systems, incidents will occur. As a result, they exert considerable effort to contain incidents and minimize impact.
So how does NSM LHIN fare? By my assessment we are doing quite well. I see evidence of human factors engineering and HROs reflected in our approach to improving patient safety. We have a robust risk event reporting system in place; the data is routinely analyzed and themes and trends are reviewed for potential quality improvements. Critical incidents and serious event trends are the focus of a Quality of Care Review where subject matter experts are engaged in creating a fulsome understanding of the factors that contributed to the event and making recommendations for improvement. We have a robust Enterprise Risk Management Framework and are continuously increasing capabilities and capacity for risk management within the organization. And, given the expanded mandate of the LHIN post-transition, we are looking at how to expand these approaches at the broader health system level.
But this is only what I see. What I don’t know is what care providers see. I encourage them to always be on the lookout for things that could go wrong and be vigilant about reporting risk events, including near misses. If there was one thing that we could do to increase patient safety, what would it be?
I reflect back to that recent news story, a prime example of a near miss. What has been reported is that the first alert that something was amiss came from the pilot of the first jet on the taxi-way who reported to the control tower that another jet had passed directly over-top. That triggered a chain of events that had the control tower communicate to the jet to pull up and go around, avoiding what could have been the most catastrophic accident in aviation history.
I encourage my colleagues in health care and beyond to communicate in the interests of increased patient safety during Canadian Patient Safety Week, and every day. That’s one way in which we can all make care safer.
Debbie Roberts is Vice-President, Quality and Performance, with the North Simcoe Muskoka Local Health Integration Network. She is a collaborative leader and strategic system thinker with over 20 years of experience in home and community care in North Simcoe Muskoka. As Vice-President, Quality and Performance, Debbie provides strategic and operational leadership, direction and oversight in the areas of quality, risk management, privacy and records management, patient services contracts, information technology, business intelligence and performance reporting at an organizational and system level.