Seeking out global patient safety research

By John Tingle

Unsafe health care is a problem of global proportions .The remedies and solutions to many patient safety problems are unlikely to be found in just one countries health care system. Health is one of the world’s great generics, it transcends countries borders, we are all dealing with the health of human beings which is the common denominator. Whilst country contexts may change the subject matter, the patient, remains constant. WHO state:

“Ensuring the safety of patients is a high visibility issue for those delivering health care – not just in any single country, but worldwide. The safety of health care is now a major global concern. Services that are unsafe and of low quality lead to diminished health outcomes and even to harm. The experience of countries that are heavily engaged in national efforts clearly demonstrates that, although health systems differ from country to country, many threats to patient safety have similar causes and often similar solutions (p.1).

Seeking out global patient safety information hubs

From a global patient safety and health security perspective we should all try to learn from each other and avoid the costly mistake of trying to reinvent the patient safety wheel when a possible solution already exists in another country. This is however much easier said than done as tracking global information and research reports on patient safety is no easy task.

A recent report from a major US Patient Safety Organization (PSO),The Centre for Patient Safety (CPS) provides some very useful insights into patient safety problems which have global relevance.

CPS has recently produced its annual patient safety organization report which details several important patient safety trends and developments.An analysis of this report can help inform the development and practice of patient safety globally as many useful lessons can be learned. Several trends are identified which include:

Behavioral Health

Violence against health care workers is noted. There are reports of health care workers, primarily nurses, being spit on, kicked, hit and verbally abused. Communication, the report states is key to understanding this issue and it is an area where leadership is vital so that staff report the abuse.

Falls

CPS  calls falls a, ‘decades old problem’. The total number of falls reported to CPS was 3,308 with ten of those claiming a harm level of death or severe harm. Most of the deaths were associated with intracranial bleeds.Fractures also occurred. Toileting as an activity prior to the fall was commonly reported.

A recurrent patient safety problem which is frequently mentioned in this report and which to my mind gives it a special value is that of ‘communication failures’. These appear frequently in the analysis of incidents:

“Communication with patients regarding fall risk potential was documented to be a challenge. Factors that play into the communication include dementia, confusion, and medication. Communication among staff regarding a patient’s fall risk potential also showed as an area for improvement (p3).

This finding will equally apply to NHS care and in probably most other health care facilities across the world. In general, poor communication strategies and practices should be a relatively easy problem to fix but they seem set as a permanent global patient safety fixture which steadfastly refuses to go away.Another trend seen in CPS is failures in written communication, poor documentation.

Surgery/Anesthesia

Failures in communication also feature strongly in this category in the report. There were adverse events reported of wrong site surgery, wrong surgery, surgical site infections and retained objects.

CPS have published an excellent report which succinctly drills down into several key patient safety issues and trends and highlights communication as a central basic failure which can and does have catastrophic consequences. Some very useful patient safety lessons are given.