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When healthcare harms, not helps

Unsafe care in hospitals is more common than you’d think, a visiting UK expert has told a patient safety seminar.

Speaking to a Sydney audience of healthcare leaders, Professor Sir Liam Donaldson (pictured), who is the World Health Organisation Envoy for Patient Safety, said around one in ten hospital admissions are associated with some form of error leading to patient harm.

The most common types of preventable harm were falls in elderly patients, avoidable infections, and errors in use of medicines, including wrong dosages, wrong patients or wrong route of administration.

Wrong site surgery was a relatively uncommon but serious problem, Sir Liam said. He pointed to a hospital in Rhode Island in the US where one medical specialty alone – neurosurgery – accounted for three wrong-site operations in a single year.

Sir Liam said he’d had personal experience of serious error in hospital treatment.

“When I was a medical student, I broke my nose and had to have it straightened, and I woke up during the procedure. It was absolutely terrifying. I was conscious of all the cutting and drilling going on.”

Nowadays, he said, patients undergoing surgery had an electrode attached to their head to alert the anaesthetist of any brain activity. Anaesthetics is one of the areas where patient safety has significantly improved, Sir Liam noted, but other medical disciplines have not done so well.

“The most effective solutions are technological and are known as ‘forcing’ solutions. For example to combat wrong medicine errors, some systems have introduced barcoded medication scanning systems, so the computer will not let you prescribe or give a dose of a drug that’s high risk.”

But he said not all medical errors are amenable to such solutions.

“Unfortunately many procedures are behaviorally based, and they’re to do with good judgement and decision-making. Here, people need to be more aware that they’re involved in a high-risk activity.”

Involving and empowering patients in the decision-making process was key to reducing the risk of unavoidable harm, Sir Liam said.

“Giving patients information could avoid error. Basic treatment for conditions like asthma could be put into an app so that patients can check whether they’re getting the recommended treatment.”

Sir Liam said the average patient may be too deferential towards their doctor and too hesitant to ask for a second opinion.

“We’ve got to get rid of this patronising attitude that patients are passive recipients. In some cases, the patient is the expert, and they know their condition better than we do. We need to empower them with apps, mobile technology and information.”

He said healthcare has a lot to learn from how other sectors, such as the aviation industry, deal with error.

“In medicine we tend to blame the doctors and nurses, and shock horror headlines in the media don’t help either. But if you punish the person making the mistake, everyone else will cover up their own mistakes,” he said.

“We have to realise how much the system itself can be at fault. If a nurse gives the wrong drug because the two medicines on the shelf look almost exactly the same, that’s not really the nurse’s fault, it’s a design fault.”

Sir Liam’s seminar on patient safety was organised by the Sax Institute, the Australian Institute of Health Innovation and the Clinical Excellence Commission.