Dean On Campus Blog

Patient Safety – the responsibility of all health care providers

I am pleased to welcome a guest writer for this week’s blog, Professor Jennifer Medves, our Vice-Dean and Director of Queen’s School of Nursing.   Richard

Patient safety is all of our responsibility as health care providers.  We are all concerned about the adverse events that happen in health care every day.  The cost to the health care systems is significant; one report estimated the cost in the US is about $17 billion every year in direct and indirect costs (1). Reports such as “To Err is Human: Building a Safer health Care System” (1)  and in 2004 a landmark Canadian study by Ross Baker and his colleagues (2)  have raised the awareness of patient safety.  These, and many other reports and publications have made patient safety a major quality issue for health care.  As many as 37% of all adverse events are ‘highly’ preventable, nearly ¼ are related to medication error, and 1 in 13 adults admitted to a Canadian hospital will encounter an adverse event.   The onus and responsibility is on all health care providers and administrators to reduce errors, but it is a very complex issue.   We have evidence that some practices including surgical check lists, hand washing, and medication reconciliation reduce errors.  As health care providers we now need to develop ways to reduce all errors and aim for robust systems that identify potential adverse events before they happen.  The first step is to stop blaming and shaming individuals and work together to find system solutions.  Once we have better ways to provide care we then must teach it to learners in our education programs.

Queen’s University hosted the first Patient Safety Educators Program (PSEP) – Canada  Become a Patient Safety Trainer conference over three days at the beginning of January 2012.   The Canadian Patient Safety Institute (3) in partnership with Northwestern University in Chicago has put together a very exciting program to train patient safety trainers for clinical settings.   Lead designers were Linda Emanuel (4) and Richard Bell (5), both of whom attended and presented at the conference.  Faculty at Queen’s requested that the program be modified to assist university educators to teach patient safety to pre and post registration learners and both CPSI and Northwestern were very keen to train educator.   The PSEP program attracted 46 participants with master facilitators including Drs David Goldstein and Roy Ilan from Queen’s brought the number to 60.   The PSEP program utilized the David Walker Atrium and three classrooms in the new School of Medicine building, the first time an outside organization has run such a large event.

Although all the participants worked hard we had fun and were able to take lots of pictures including one of the School of Medicine physicians many of whom are Program Directors of their post graduate training programs.  We also welcomed colleagues from Renfrew Hospital and hospitals in LHIN 10.   This is a first step to develop health care professionals for the future who understand the complexity of patient safety and become advocates for quality care that keeps the safety of patients central to our care.   The PSEP conference is the first step in making health care safer for all patients, reducing the cost of error, and helping us understand our responsibility.  Next steps are up to us all particularly the 46 who participated.  We are looking to everyone to help us.

If you would like more information about the PSEP program the link to CPSI is below, if you would like us to host the program again, or if you have comments please send them to me at jennifer.medves@queensu.ca or drop by my office door is always open – 127 Cataraqui Building.

 

(1)   Kohn L T, Corrigan J M, Donaldson M S. (Eds) (1999).  To Err is Human.  Washington, DC: Institute of Medicine, The National Academies Press.  http://www.nap.edu/openbook.php?isbn=0309068371

(2)   Baker, G R, Norton P G, Flintoft, V, Blais, R, Brown, A., Cox, J et al (2004). The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada.  CMAJ, 170(11), 1678-1686. http://www.ecmaj.ca/content/170/11/1678.full

(3)    Canadian Patient Safety Institute http://www.patientsafetyinstitute.ca/English/Pages/default.aspx

(4)   Contact information for Dr Emanuel http://fsmweb.northwestern.edu/faculty/FacultyProfile.cfm?xid=11207

(5)   Contact information for Dr Bell http://fsmweb.northwestern.edu/dept-profile/deptFacultyProfile.cfm?xid=10065

 

6 Responses to Patient Safety – the responsibility of all health care providers

  1. Chris Smith says:

    Thanks for information about the exciting development of setting up a patient safety educational program. One issue that has really bugged me since my arrival here though has been that the hospital does not currently have any kind of system whereby we can safely hand over patient care from one shift to another, let alone from one block to another when residents/staff change. The lack of a secure information system where information about patient problems, issues that need to be addressed etc. is a major patient safety weakness. With multiple trainees (residents and students) involved in patient care, the fact that we cannot model a good system with pertinent hand-over of critical information, means we seriously lag behind other teaching hospitals in appropriate, informed transfer of information. Every night residents are writing and re-writing hand written notes about patients and that is clearly not the best process. We can and should do much better. It just needs to be set as a priority.

    • reznickr says:

      Dear Chris,

      I would certainly agree that electronic handover is an important goal. We should all work towards that end.

      Richard

  2. Charles T. Low says:

    It was a great weekend learning event. The formal discipline of Patient Safety is so “right” and so clearly necessary that, as a cause, it deserves the most serious advancement.

    I think I’m condensing it correctly if I say that it is i) as much a culture as ii) it is a collection of well-researched organizational techniques to keep patients safer. The culture is one of pervasive communication and engagement, based on what has been described as embodying “complete respect for each individual, all the time, no exceptions”. That, however, is a very tall order, and the ways to accomplish that are manifold. It’s also a very dynamic process, given the “complex adaptive” system in which we work – simple prescriptions and long-range detailed plans are often inadequate and counter-productive, and yet significant progress is possible, given favourable conditions.

    To me, it all comes down to this: are we serious about taking safer care of our patients? Surely that is what we actually collectively wish to do. If so, this topic requires a much wider dissemination, on many levels.

    It was wonderful to be with such a committed group. The word is spreading!

    Charles T. Low
    Brockville Anesthesia

    • reznickr says:

      Dear Charles,

      Thank you form your thoughtful comments. I very much agree with your analysis that the benefits of patient safety initiatives derive just as much from a change in culture, as they do from change in processes. I had the wonderful opportunity of collaborating on the WHO project for the safe surgical checklist. We found decreased morbidity and mortality rates in the checklist group. Many of the investigators, myself included, believe that the change of culture in the O.R. was the “operative effect”. (Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AS, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor BR, Gawande AA: A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England Journal of Medicine 2009: 360:5: pp 491-499)

      Thanks again for your insights.

      Richard

  3. Karen Hall Barber says:

    I attended this conference with 3 others from our Queen’s Family Heath Team. Kudos to Jenny and her team for hosting it splendidly and for Dean Reznick for promoting it. Jenny is on our Board of Directors and by the questions that she asks us it is clear that she is passionate about promoting patient safety and challenging health care providers to raise the bar in this realm.
    At Queen’s Family Health Team we are caught up in this zeal and have some exciting initiatives going on to teach our physicians of tomorrow about patient centred care, quality improvement and patient safety.
    Kudos to Dean Reznick and Jenny.
    Thank you for all of the hard work that went into this.
    Karen Hall Barber,
    Assistant Professor Department of Family Medicine,
    Physician Lead, Queen’s Family Health Team

    • reznickr says:

      Karen, as you suggest, Jenny Medves should get lots of credit for spearheading this initiative. It’s great to see our FHT so involved in this issue and helping Queen’s lead in this initiative.

      Richard

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