Healthcare is a high-hazard industry and each year, hospital staff, patients and their families suffer because of mistakes that could often be avoided. This was the subject of the first ever patient safety symposium hosted by Hamilton Health Sciences (HHS) and marks an important step forward for an industry that needs to learn how to understand, deal with and learn from medical mistakes.
Dr. Andy McCallum, HHS Chief of Staff, was instrumental in organizing the symposium that he hopes will become an annual event. Partnering with Dr. David Rosenbloom, Director of Pharmaceutical Services for HHS, Dr. McCallum provided an overview of some of the major issues that contribute to clinical errors and jeopardize patient safety. “These are not cases of bad health professionals doing bad things,” Dr. McCallum said. “We’re talking about good, highly-competent professionals involved in bad outcomes. Rarely are the outcomes attributable to one individual. These are system problems that must be addressed together.”
The failure to check and recheck actions of all members of the care team poses the biggest threat to patient safety. Dr. McCallum said there are several strategies that can be used to help eliminate errors:
- Reducing reliance on memory
- Improving access to information
- Standardizing tasks
- Reducing the number of hand-offs to other caregivers during the care process
- Error-proofing practices
Although Canadian hospitals have only recently begun to track error-related statistics, it is estimated that up to 10,000 Canadians die each year as a result of medical mistakes made in hospitals. In order to get a better handle on the numbers and the situation, the Canadian Institute of Health Research (CIHR) and the Canadian Institute for Health Information (CIHI) have launched a joint study that will randomly examine hospitals and patient charts across the country. The results of the study will be released in 2003 with the objective of using the identified errors as an opportunity to make improvements across the entire system.
Using the aviation industry as an example, Dr. McCallum pointed out that errors and information related to mistakes are widely published so that the industry, as a whole, can learn and take measures to correct mistakes that could potentially be repeated. This non-punitive approach encourages openness and support and uses mistakes as broad-scale learning opportunities that help the entire field move forward. Healthcare, on the other hand, has traditionally gone to the other extreme, keeping errors under wraps for legal reasons. This has created a punitive environment where medical practitioners are seldom given the opportunity to apologize for mistakes and rarely have a chance to provide education to the profession as a whole.
“In healthcare, there is a tendency to blame people for making mistakes rather than trying to understand the factors that led to the mistakes in the first place,” Dr. McCallum said. “We need to move away from this and start working together so that we can share information and create a culture of understanding and open communication.”
The symposium was co-hosted by St. Joseph’s Healthcare and McMaster University and brought together experts from across the country. Murray Martin, HHS President and CEO, said the symposium was a milestone for the industry.