Improving patient safety in our hospitals

November 4, 2014 by Dr Brian Robinson

Hospitals are dangerous places. This week, the Health Quality and Safety Commission released 'Making Our Health and Disability Services Safer', a report summarising 454 events of patients who were injured or died due to errors or mistakes reported by our District Health Boards in the past year.

Research in New Zealand DHBs indicates that around one in ten of us who enter public hospitals experience a preventable mistake or error in our care. These events include wrong drugs or doses being administered, operations being performed on the wrong part of our body, or lost x-rays and lab results leading to missed diagnoses.

On nearly all occasions these incidents are either unnoticeable, involve some discomfort or a longer hospital stay. But for about one in a hundred, the outcome will be much more severe and result in permanent injury, and about one in three of these severe events will result in death.

These numbers may seem high, but they are not unique to New Zealand and are very similar to data gathered in Australia, the United States and the United Kingdom. The data has been known and discussed in healthcare circles for the past 15 or more years.

Furthermore, the cost of fixing these mistakes and errors is thought to consume about one third of our health budget. If you then add to this figure the personal costs for those individuals and families who experience an injury or death, the cost is immense.

To me, however, the number of cases reported by the Commission, 454, simply doesn't add up. With over one million New Zealand public hospital admissions each year, I would expect in excess of 10,000 preventable serious adverse events to occur. It seems that there must be a large number of incidents that are not being reported to the Commission.

Why would this be? Research shows a variety of reasons for non-reporting by . These include a culture or hierarchy of not reporting: "I don't do it as it isn't my job—it's a nursing role", a fear that management will use reports against clinicians or result in disciplinary action, a belief that mistakes are an acceptable part of overworked and underfunded health systems, and a view that reporting is unheard, dismissed or will not make any difference.

To patients, these reasons must surely sound completely unacceptable. However, attempting to report all mishaps would be a futile exercise: not only would it require a major shift in attitude by many health practitioners, in terms of the sheer volume it would consume vast resources when DHBs and the Commission already appear overwhelmed by current reporting levels.

Perhaps rather than numbers we should focus our attention, as Don Berwick, an internationally recognised patient safety leader, says on the genuine sharing of knowledge by health providers: "Measurement contains almost no information. What we need are stories…we need firesides not spreadsheets.

"While several New Zealand DHBs do present detailed and open stories on their websites, others appear less comfortable and use the coded language of bureaucracy. For example: "Patient received a repeat, unnecessary procedure due to miscommunication".

I am unsure who this information is intended for, or whether this tells me how safe that hospital is, but it does tell me that miscommunication is happening on many levels.

I suspect most people would be more interested in watching Embarrassing Bodies than delving into their local DHB website to decipher these stories to understand how safe their care would be!

The report released by the Health Quality and Safety Commission also does not tell me how safe our hospitals are. I get the sense that Commission is reassuring us that something is being done and we should 'keep calm and carry on'. The people who do know how safe a hospital is are the professionals on the front line.

Marty Makary, an American surgeon and patient safety expert, has suggested three questions hospitals should regularly ask their staff and make publicly available:

  • Would you have your operation at the hospital in which you work?
  • Do you feel comfortable speaking up when you have a safety concern?
  • Does the teamwork here promote what's right for the patient?

While our hospitals do survey staff about safety culture, we the public, who pay for and get treated in these hospitals, do not get to see the results.I suggest that it is the answers to these three questions that we all should be able to see. This should become the first item of business at all DHB meetings that management are responsible and accountable for, to help make us safer in our hospitals.

Explore further: Hospitals use performance on publicly reported quality measures in annual goals

Related Stories

Hospitals use performance on publicly reported quality measures in annual goals

October 6, 2014
A majority of hospitals reported incorporating performance on publicly reported quality measures into their quality improvement efforts, however many hospital leaders expressed concern about the clinical meaningfulness of ...

Families report adverse events in hospitalized children not tracked by health-care providers

November 21, 2011
Families of hospitalized children can provide valuable information about adverse events relating to their children's care that complements information documented by health care professionals, states a study published in CMAJ ...

Gov't report: Hospitals improving patient safety

May 7, 2014
The government says hospitals are becoming safer for patients due to a quality improvement partnership between industry and federal agencies.

Making light work of the workload for overworked healthcare workers

September 23, 2014
Modern hospitals are staffed by overworked and overstressed healthcare workers, according to a research paper published in the International Journal of Biomedical Engineering and Technology. As such, new technology must be ...

Malpractice study: Surgical 'never events' occur at least 4,000 times per year

December 19, 2012
After a cautious and rigorous analysis of national malpractice claims, Johns Hopkins patient safety researchers estimate that a surgeon in the United States leaves a foreign object such as a sponge or a towel inside a patient's ...

Researchers create 'black box' for use in operating rooms

July 8, 2014
Researchers at St. Michael's Hospital have developed a "black box" for using in operating rooms, similar to that used in the airline industry.

Recommended for you

Researchers see popular herbicide affecting health across generations

September 20, 2017
First, the good news. Washington State University researchers have found that a rat exposed to a popular herbicide while in the womb developed no diseases and showed no apparent health effects aside from lower weight.

One e-cigarette with nicotine leads to adrenaline changes in nonsmokers' hearts

September 20, 2017
A new UCLA study found that healthy nonsmokers experienced increased adrenaline levels in their heart after one electronic cigarette (e-cigarette) with nicotine but there were no increased adrenaline levels when the study ...

Higher levels of fluoride in pregnant woman linked to lower intelligence in their children

September 20, 2017
Fluoride in the urine of pregnant women shows a correlation with lower measures of intelligence in their children, according to University of Toronto researchers who conducted the first study of its kind and size to examine ...

India has avoided 1 million child deaths since 2005, new study concludes

September 19, 2017
India has avoided about 1 million deaths of children under age five since 2005, driven by significant reductions in mortality from pneumonia, diarrhea, tetanus and measles, according to new research published today.

Gulf spill oil dispersants associated with health symptoms in cleanup workers

September 19, 2017
Workers who were likely exposed to dispersants while cleaning up the 2010 Deepwater Horizon oil spill experienced a range of health symptoms including cough and wheeze, and skin and eye irritation, according to scientists ...

Study suggests link between youth football and later-life emotional, behavioral impairment

September 19, 2017
A new study has found an association between participation in youth tackle football before age 12 and impaired mood and behavior later in life. The study appears in Nature's Translational Psychiatry.

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.