KIM OATES. An insidious tragedy

Imagine what would happen if a fully laden 747 airliner crashed in Australia every week for a whole year. There would be public outcry, an outrage, swift political action and  an enquiry at the highest level, possibly a Royal Commission.

What most people don’t realise is that the number of people dying in that fearful scenario is the same as the number who really do die each year in Australian hospitals due to avoidable error. Reliable estimates suggest that 18,000- 27,000 such deaths occur annually, with an additional 50,000 suffering permanent injury. But unlike an aircraft tragedy, this tragedy is insidious. Quite apart from the human tragedy, it is estimated that the costs to the health system in terms of extra time needed in hospital, drugs and equipment approximates to $4 billion/year.

We are proud of the Australian health system. There is universal health cover. No one is denied treatment. Most of the outstanding  hospitals are government funded, where patients need pay nothing for excellent care. But we still have error that harms patients.

This problem is not unique to Australia. Figures from other countries with well developed healthcare systems all report avoidable adverse events ranging from 8-12% of hospital admissions.

Why is healthcare dangerous? Those of us who work in health don’t leave home each morning thinking about what harm we are planning for that day, just the opposite. But multiple factors thwart our good intentions, including: vulnerable patients; the complexity of health care;  communication errors; poor organizational culture; inadequate teamwork and not involving the patient in the healthcare team.

Some patients are vulnerable, because they have multiple health problems, or more often because of communication problems such as in the elderly (if confused or with hearing impairment); with young children (where communication can be difficult and where rapid deterioration is more likely); in the mentally ill and in those with limited English-speaking skills.

Modern health care is complex. We sometimes place over-reliance on technology. Complex equipment keeps being updated with little standardisation across wards and departments so that staff moving from one area to another may be expected to master unfamiliar equipment. There are interruptions, distractions and urgency. The nature of the work has small margins of safety. There is incomplete knowledge about many diseases.

Errors of communication are a common reason for error. The airline industry has taught us that flattening the hierarchy makes it easier for a junior person to speak up if they detect a problem. We have only recently realised assertiveness training can help juniors to speak up in the patient’s best interests. We are learning the importance of communication techniques such as check-back, time out (e.g. correct patient, correct procedure, equipment available) before commencing a procedure, debriefing  (problems we encountered, what went well, what we could do to improve) following a procedure and the value of listening as well as talking.

There are still areas in health where the culture is not conducive to safe care; places where mistakes are seen as opportunities for blame and discipline, opportunities to make an example of the offender. This ignores the fact that in 80% of errors, the problems are with the system. It ignores the fact that a blame culture keeps errors hidden. In contrast, the increasing trend towards a more open health culture has shown that errors are opportunities to learn, to make things safer and that a relentless focus on recognising errors helps them be prevented in the future.

My own focus in this area has been teaching the next generation of health leaders about how they can recognise and prevent error. It’s a good area to work in and very gratifying to see how quickly many of these young future leaders recognise the problems and come up with ideas about how they can make the system safer.  Some change their careers entirely, making patient safety their priority.

September 17 was the World Health Organisation’s first World Patient Safety Day. It passed quietly in Australia. Yet the accompanying WHO resolution made good sense. It called for the need to ‘pay the closest possible attention to the problem of patient safety and establish and strengthen science-based systems, necessary for patient safety and the quality of healthcare’. It noted that the burden of harm to patients from adverse events is one of the top ten causes of death and disability in the world and that most adverse events can be avoided with effective prevention strategies that instil a safety culture and a patient-centred approach. It noted that this requires strong leadership, adequate resources, robust data, and accountability.

Healthcare is a team game. The era of the omniscient professional is over. Teams are multidisciplinary.  Members learn from, respect and support each other. They have a common focus: achieving the best result for the patient. And the best teams have the patient as an integral part of the team. Patients are listened to and respected, given information that helps them make informed decisions about their care and their observations are valued, rather than dismissed.

While the dangers of healthcare must not be underestimated, progress is being made. Bodies such as the Australian Commission on Quality and Safety in Healthcare,  the Clinical Excellence Commission in NSW and its counterparts in other states are providing training, advice and monitoring data, all with a view to making health care safer.

Whether we are lay people or health professionals, we can all contribute to our own safety or the safety of our loved ones when healthcare is needed. We need to encourage people not to be afraid to ask questions, particularly if they are worried or if something doesn’t seem right. If the doctor is communicating in jargon, ask for a layperson’s explanation.  Ask, ‘What are my options?’ ‘What are the risks?’ If in doubt, ask for another opinion. In a safe healthcare system every patient has a right to be an equal partner in their own care.

Kim Oates AM MD DSc MHP FRACP FRCP FAFPHM is a consultant at the Clinical Excellence Commission in NSW, Australia and Emeritus Professor in the Discipline of Child and Adolescent Health at Sydney University.

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2 Responses to KIM OATES. An insidious tragedy

  1. Eugenie Lumbers says:

    I was delighted to see that you equated health care management to 747s and commercial flying. I have been thinking about the cross checking that goes on on flight decks and the continuous input of by at least two individuals in managing the procedures involved.
    Then there is built in redundancy to prevent a system failure.
    I wonder why there is not more such crosschecking in hospitals, why patients are discharged with potentially serious problems after only minimal assessment often by junior staff.
    A major issue is of course lack of staff and long hours worked.
    A pilot is only allowed to fly for 8 hours without a rest. yet interns and nursing staff will do very long shifts leading to sleep deprivation and errors.

  2. Philip Bond says:

    Central to this is staff profile i.e. numbers (and salary) of those working in the system specifically nursing. Too few, underpaid and working long hours equals burnout.

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