Breaking the mould in patient safety

Impact of hospital interventions

Current safety interventions are evaluated using patient safety indicators that have been selected for their feasibility of use and potential efficacy.4 Most indicators measure the frequency of adverse events such as surgical site infections, wrong blood type, drug related adverse events, patient falls, and postoperative pulmonary embolism. Other indicators address the causes of errors and assess processes such as the quality of medical records, prescriptions, and handover processes. These indicators are used in accreditation programmes and large scale campaigns inviting healthcare organisations to take part in quality improvement and benchmarking activities.5

Improvements have been reported in health professionals’ acknowledgment of the importance of the quality and safety, their use of adverse event reporting systems and electronic charts, and the handling of dangerous materials and drugs such as anticoagulants, antibiotics, and anticancer drugs. The greatest improvements have been observed within the framework of dedicated campaigns. But despite all the enthusiasm and effort, clinical results have been disappointing. Although the use of a variety of indicators has resulted in more attention to procedural checks (such as prevention of wrong site, wrong patient, wrong procedure events), there is little evidence for a significant reduction in the numbers of adverse events.6 7 8 Compliance with even well accepted safety recommendations remains low. Only 55% of surgical patients receive antimicrobial prophylaxis and only 58% of those at risk of venous thromboembolism receive the recommended preventive treatment.9 10

There are at least three reasons for this poor performance: low adherence, narrow scope of interventions, and a limited evidence base.

Need for a broader approach to patient safety

Easy access to care is a sign of a quality service. Most debates on access have been dominated by political issues tackling health inequalities.18 However, effective access is much broader than this and should include other areas that affect patient safety such as any gaps occurring in a patient’s care. This may include access to out of hospital carers, appropriate referral by general practitioners to specialists, timely and efficient admission to the right hospital department, effective reconciliation of drugs, and continuity of care after discharge from hospital. Access should ideally be patient centred and include availability, appropriateness, preference, and timeliness. One or more of these characteristics is often missing in patients’ healthcare experiences.21

Safety may be defined as increasing the patient’s chance of receiving appropriate care that is in line with evidence based medicine. Any obstacle to such access is considered as a loss of chance and a potential failure of the healthcare system.

Measuring safety related errors in access to care

Measuring errors due to absence of adequate care is not easy. Two sets of indicators can give some idea of the risk associated with inappropriate access to care: a set of global indicators for mostly chronic conditions and a set of patient safety indicators for mainly acute conditions.

The first set includes amenable mortality, which is widely used in Europe, and hospital discharges for avoidable hospital conditions, which is used in the United States and is considered to be a valid measure of access to timely and effective primary care.22 An effective primary care system minimises mortality from preventable conditions and can reduce hospital admissions for disease flare ups—for example, in congestive heart failure, pneumonia, diabetes, and asthma. Amenable mortality is a summary measure that captures the consequences of poor access to clinical prevention, primary care, and specialty services.23 For 2002-3 in 19 OECD countries, it accounted for an average of 23% of total mortality in males under 75 years of age (15-27%) and 32% in females (25-36%). The figure⇓ shows the relative improvement in amenable mortality between 1997-8 and 2002-3. As expected, the improvement was much bigger for countries with poor results in 1997-8. The figure also suggests that there is probably a lower threshold beyond which the death rate cannot improve.

Improvement in amenable mortality for males aged 0-74 years in OECD countries between 1997-8 and 2002-3 (based on results published by Nolte and McKee²³). The lines indicate the borders of the disparity of results between countries. These can be projected (dotted lines) to suggest a threshold below which the amenable mortality could not be further reduced

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The second set of indicators concerns timely and effective access to hospital for mainly acute diseases. The following three examples show the link between access and patient safety.

Acute myocardial infarction—One year mortality decreases with early revascularisation of coronary arteries compared with out of hospital thrombolysis and in-hospital thrombolysis or angioplasty.24 However, benefits are dependent on a care pathway offering direct access to the hospital cardiologist and bypassing the general practitioner or emergency department saves time and lives and reduces long term effects.25

Stroke—For stroke victims to benefit from early thrombolysis requires rapid, synchronised, action, maybe with advice obtained by video conference. Transferring the patient to a specialised unit may seem the safest option but can result in loss of precious time.26 27

Hip replacement—Patients require appropriate care after discharge from hospital. In Sweden, an integrated care pathway offering rapid preoperative attention, continuity, and an accelerated training programme tailored to the patient’s needs significantly reduced inpatient complications and 30 day readmission rates.28

Causes of shortcomings in integrated care, referrals, and access

In countries without universal healthcare systems, poor access to care is often considered to be a problem confined to people without health insurance. Financial obstacles can aggravate diseases and the risk of adverse events. Many studies have shown that poorly insured people face a double risk. They have less access to care and, when they do gain access, their disease and disability are more severe.29 30

However, most adverse events relating to poorly integrated care, inappropriate referral, and poor access are due not to financial but to organisational issues such as lack of timely access to the right healthcare practitioner and intervention. In-hospital and out of hospital risks tend to potentiate each other, especially in chronic diseases. For example, patients with chronic kidney disease are at a significantly higher risk of adverse events from inpatient care.31 The number of hospital admissions increases when waiting times are long and the hospital is far away and does not offer the specialists and imaging techniques required. Such avoidable hospital stays are often associated with adverse events and are on the increase.32

Implications of broader definition of patient safety

The above broader view of patient safety that includes access to care has at least two advantages. It enables the cumulative measurement of the global negative outcomes over a given period of a patient’s life such as short and long term complications rates, short term (30 or 60 days) post-discharge mortality, amenable mortality, avoidable hospital admission, and health expectancy. Healthcare providers should find such global measurements more meaningful and useful and thus be more likely to engage with them. The broader view also offers an opportunity to go beyond the person approach and address the system approach fully, thus breaking the mould of the usual medical silos and tackling interfaces and flows rather than dedicated protocols.

This broader view of patient safety, however, also has theoretical and methodological implications. The concept of ineffective access is closely associated with failures in the integrated care pathway. Negative outcomes often result from accrued poor performance over time, with some acceleration here and there during acute episodes. Many failures are due to poor strategies and errors of omission (not taking a decision) rather than errors of commission (performing a specific care procedure incorrectly). The measurement and analysis of global negative outcomes thus requires a technique that does not seek a causal factor in the last protocol applied but considers adverse events throughout the patient’s care.

We suggest defining a new category of adverse events—integrated adverse events. These are not necessarily related to a single event but to repeatedly making poor strategic choices and to poor organisation of care, thus causing delays in appropriate care. For example, in one US study, clinicians reported missing clinical information in 13.6% of visits, including laboratory results (6.1% of all visits), letters (5.4%), radiology results (3.8%), history and physical examination (3.7%), and medications (3.2%). The missing information was considered to be at least “somewhat likely” to affect patients adversely (44%) and to result potentially in delayed care or need for additional services (59.5%).33 Another US study based on insurance claims concluded that diagnostic errors that harm patients were typically the result of multiple breakdowns involving individual and system factors.34 The most common breakdowns in the diagnostic process were failure to order an appropriate diagnostic test (55%) and failure to create a proper follow-up plan for transition of care (45%).

Conclusions

Most current safety interventions are an ethical, emotional, and insurance driven response to specific incidents in hospitals. We need to move from this reactive approach to a more proactive and integrated approach. It is well known in the field of complex system control that professionals losing control of a situation tend to tackle just that part of the overall problem where no error is possible. The rest of the problem and its final outcome are left to so called “collective” action.35 Such an attitude threatens patient safety. Creating champions with an outstanding safety record in their narrow technical field may actually hide a gradual deterioration in the system as a whole. A growing number of patients will have difficulty in accessing these top professionals.

We recommend eliminating the divide between hospital safety interventions and out of hospital care strategies. A broader view of patient safety will mean that adverse events no longer relate only to episodic errors and failures in procedures at specific times but also to cumulative failures throughout a patient’s journey within the health system. The emphasis moves from process errors and single outcomes with relatively little influence on long term prognosis, to the accumulation of poor referrals and poor access that have a big effect on overall outcome.36 Patient safety interventions should no longer be assessed just by counting adverse events but by measuring the effect of opportunity losses on patient outcomes, notably in terms of avoidable hospital admissions and amenable mortality.