What are the challenges for patient safety?

There are a number of challenges for patient safety. Many think that technology will solve all the problems and will make things safer but that is not always true and care needs to be taken when implementing new systems. Technology has contributed immensely to improving safety in other industries such as aviation and the nuclear industry and we must learn from them. In healthcare however, we have many different technologies and the added issue of the individual patient with the complexities of their condition - any one patient can have many different technologies in use to care for them at any one time and many different doctors and nurses in the team needing to be trained to use each device or technology. Given this background, safety in healthcare becomes very complex.

But is it really more complex than the nuclear industry or aviation?

It might not necessarily be more complex but there is more work to do – much more work. Safety improvements have been underway in other fields such as nuclear power and aviation for decades now. Safety in healthcare, on the other hand, started to be looked at in earnest after the publication of the Institute of Medicine Report ‘To Err is Human’ in 1999. I think we all recognise that healthcare has still a long way to go.

There was an EU survey some years ago which also stated that healthcare was lagging behind other industries when it comes to safety procedures. As a consequence, the authors recommended using innovative technology like electronic patient records. Do you agree with this approach?

Technology is certainly one aspect of increasing patient safety. But it is only one aspect. You also have to think about social aspects such as the organisational culture in medical institutions, like the ability of staff to speak up and admit when things go wrong so the organisation can learn. You also have to consider the environment in which people work and how this impacts on their ability to work safely. When it comes to technology, electronic patient records have an important role to play in patient safety. But issues like confidentiality of data, completeness of the records and who has access need to be considered. In the UK, for example, we have electronic records in primary care, but often they are not accessible by doctors in acute hospitals. So in reality, the doctors work with electronic documentation and paper documentation in parallel. This is far from ideal.

What other technologies can be of interest to increase patient safety?

There is a lot of technology in pharmacy that can really help to reduce errors and accidents with medication. When information about a patient’s drugs is transferred from one form to another on paper and then between hospitals, doctors and pharmacies, for example, there is a lot of room for errors. Many of these can be avoided by using electronic prescriptions. Decision support tools for doctors, too, can improve patient safety. Simple systems to help with calculations for drug doses, for example in paediatrics, where drug dosing can be dependant on factors such as a patient’s weight or in renal medicine where there are multiple drugs prescribed that can interact. Other technologies that are currently being investigated include RFID-tagging in operating theatres. RFID technology can be used to tag instruments, so that a patient can be scanned after an operation in order to see if some instrument was left inside. RFID-tagging of patients is also an option to avoid wrong treatment or to track patients within big medical institutions.

Technology can help to avoid errors. But isn’t it also a source for new errors?

It is. Take electronic prescribing systems. These often present the drugs in drop-down-menus in alphabetical order. This can lead to dangerous situations when the doctor, by accident, chooses the neighbouring medication on the list. The problem can be avoided by using safety queries or alert systems. Another problem with potential safety implications is the loss of electronic patient data. Workflow is also critical. For example one electronic dispensing machine would not allow the staff to dispense any medication until the drug was checked against the patient’s bar code on their wrist band. As a consequence, the nurses started to stick the labels of the bar codes on the bedside tables because the bar code reader wouldn’t read a label that was bent around a wrist – it needed to be flat. This meant that unless the label was removed from the table when the patient was discharged, the next patient in the bed could be given the wrong drugs.

How can such situations be avoided?

You really have to think about the design of the interface between the person and the machine. If you get into a car, for example, you know that the brakes, the accelerator and the steering wheel are roughly at the same place every time. If you want to use an infusion pump, the number buttons should always be in the same order – this isn’t always the case. It can happen that one company uses a key pad with 1-2-3 in the top row, and another one has 9-8-7 in the top row. This can cause all sort of confusion, especially when people think they know the machines and start to use them automatically. So what is needed is standardisation, not only on a national level but internationally, since most medical device companies are global companies and medical and nursing staff now move to work in many different countries.

Where would we be as a society if the nuclear power industry and the aviation industry had the same safety standards like the healthcare industry?

I don’t think many of us would fly, and I don’t think we would have many nuclear power stations. When you get on a plane, for example, the pilot would not take off without doing a safety briefing and a safety check of all the equipment. In healthcare, research shows that preoperative safety briefing in operating theatres do not routinely happen. And equipment is not checked regularly. This would simply not happen in aviation.

But why is that? Could it be that the safety debate is still too academic? Do we need to involve healthcare professionals, nurses and doctors, more into the discussion?

Doctors and nurses are regularly involved in patient safety alliances, so things are changing. I would look at it positively: Nobody could have imagined five years ago that patient safety one day will become a topic of a conference like this(*). So there is political pressure behind it now at an EU level. More and more people are involved, including doctors and nurses. We need activities on all levels. So it is good that many people are involved.

Despite all problems with technology: Does it bring more benefits than dangers in the end?

With care and attention it definitely does. (AS)

(*) HealthTech Wire interviewed Susan Burnett at the European Commission’s “eHealth without frontiers” conference in Slovenia. For further information on the conference, pls. visit the GoDirect channel at www.healthtechwire.com/ehealth2008.