Most of the time, people’s experiences as patients, family members, and healthcare providers in the healthcare system are positive. However, at times things do not go as planned.
In Canada and the world, there are significant numbers of people who are harmed or who die as a result of their care and not the treatment process or risks involved. In a 2004 study[1], using data from 2000, there was an adverse event rate of 7.5% in acute care hospital admissions in Canada. By extrapolation, it was estimated that:
- 185,000 of 2.5 million similar admissions to acute care hospitals in Canada were associated with an adverse event
- close to 70,000 of the adverse events were potentially preventable
- between 9,000 and 24,000 Canadians died from adverse events that could have been prevented.
Since the 2004 study, studies in pediatric healthcare and home care have been conducted. The Canadian Pediatric Adverse Event Study[2] involved 22 hospitals in 7 provinces. The study determined that 9.2% of children hospitalized in Canada experience an adverse event. “Safety at Home – A Pan-Canadian Home Care Study” found the rate of adverse events in Canadian home care clients was 10 -13 per cent over a period of one year[3]. Extrapolating to the over one million home care recipients per year in Canada suggests that up to 130,000 Canadians receiving home care experience an adverse event, with half being considered to be preventable. Acknowledging that patient incidents do happen is important to taking personal and organizational steps to improvement.
Patient safety involves the complex interaction among institutions, technologies, and individuals, including patients themselves. In other words, patient safety is everyone’s responsibility.
Healthcare providers try to do the right thing, but because they work in a complex, imperfect system with many variables, at times patient safety incidents reach the patient. Some incidents do not cause harm, but others do affect patients – the people health providers are committed to helping.
The tradition and culture of healthcare provision has been one that suggests that error is unacceptable, and acknowledgement of mistakes is an admission of lack of skill. It has become evident from our successes, and from patients who have been harmed during the healthcare delivery process, that this approach has deterred the development of a culture that supports learning and improvement.
A key strategy to support your learning is to reflect on basic concepts of patient safety, and how you can apply these concepts in your daily practice. Over the next seven newsletters, a key patient safety topic will be highlighted, including questions to stimulate self-reflection of one’s own practice. Topics to be covered will be aimed at providing answers to the following questions:
- How do key human and environmental factors contribute to patient safety?
- What is a culture of patient safety?
- What are the key elements of effective patient and family centred care?
- What are key factors that promote effective teamwork in multidisciplinary healthcare teams?
- What are key interpersonal and communication skills required for effectively working with patients and families, and within multidisciplinary healthcare teams?
- What are the major concepts related to recognizing and managing risks to patients in healthcare environments?
- What are the key elements required in responding to and disclosing harmful incidents?
Patient safety – make it YOUR responsibility!
For more information on patient safety, go to the Manitoba Institute for Patient Safety website at www.mips.ca
[1] Baker, GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, et al. The Canadian Adverse Events Study: The incidence of adverse events among hospital patients in Canada. Canadian Medical Association Journal. 25 May 2004; 170 (11): 1678 – 1686. [2] Matlow AG, Baker GR, Flintoft G, Cochrane D, Coffey C, Cohen E, et al. Adverse events among children in Canadian hospitals. The Canadian Paediatric Adverse Events Study. Canadian Medial Association Journal. 18 September 2012; 194 (13): E709 – E718. [3] The Canadian Patient Safety Institute. Safety at Home – A Pan Canadian Home Care Safety Study. 2013. Available at http://www.patientsafetyinstitute.ca/English/research/commissionedResearch/SafetyatHome/Documents/Safety%20At%20Home%20Care.pdf