Transcript fighting the war against medical errors and

Building Safe Healthcare Systems:
Fighting the War against Medical Errors
and Improving Patient Safety in
Developing Countries
Isabel Kazanga, PhD Student, Center for Global Health,
Trinity College Dublin
29th November 2010
Introduction
 Healthcare is not usually safe
as it is intended to be.
 In 1999, the IOM published a
landmark report on medical
errors: “To Err is Human”
 Everyday many people get
injured and die in hospitals
silently as a result of
preventable medical errors
(MEs)
 In USA, 44,000–98,000 people
die every year due to MEs
Source: Institute of Medicine (IOM), 1999
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Introduction cont.
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The epidemic of MEs is a
global problem.
MEs affect 1 in 10 patients
worldwide.
The incidence of MEs is
however more serious
and
challenging
in
developing countries than
developed countries.
Source: World Health Organisation, 2005
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40%
30%
20%
10%
% of patients affected
with medical errors
Research Objectives
Broad Objective
To identify priorities and strategies that can help reduce
MEs and improve patient safety in developing countries,
in order to draw suggestions for public health policy
improvement.
Specific Objectives
1. To investigate the epidemiology of MEs
2. To identify factors which contribute to MEs
3. To explain the effects of MEs
4.To identify priorities and strategies to reduce MEs and
improve patient safety in developing countries
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Significance of this Study
The findings of this study will:
- give insight into the
epidemiology of MEs in
developing countries
- provide suggestions for
policy improvement
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Methodology
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Desk research
Masters research project
Extensive literature review
Sources of data
✓ PubMed
✓ MEDLINE
✓ ScienceDirect
✓ Other sources
Keywords- Healthcare systems,
medical errors, patient safety,
developing countries
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Review & Findings
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What are medical errors?
Definition
“A commission or an
omission with potentially
negative consequences”a
(Wu et al, 1997)
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Examples
• Wrong diagnosis or treatment
• Object left inside patient
during surgery
• Mix-up in patient identities
• Delay in treatment
• Injury, infections etc
What causes medical errors?
Healthcare systems complexity issues
e.g:
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Poor organizational culture
Inadequate technology
Poor communication channels
Poor leadership
Lack of incident reporting
systems
Lack of skilled healthcare staff
Professional issues
e.g:
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Lack of knowledge &
incompetency
Failure to acknowledge and
understand how errors occur
and their consequences
Personal factors
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e.g:
High workload and busy schedules (with
many pressures and high level of stress)
Illegible hand writing & inaccurate prescription
“Beyond
honest errors are mistakes caused by negligence - haste, carelessness.”
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The epidemiology of medical errors
It is difficult to get a full
and complete picture of
medical errors in
developing countries
Why?
Due to inadequacy of research studies
and limited publications
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The Incidence of MEs in developing countries
Countries
Durban, South Africa
(King Edward VIII Hospital)
Studies on MEs
MEs occurred in 11.7% of gynaecology admissions & 52% of the
errors were avoidable. MEs accounted for 17.7% of mortality & 2.1%
of all admissions (Matsaseng & Moodley, 2005)
Bangladesh
73.5% of U/5 children with acute diarrhea received inappropriate
treatment (Alam et el, 1998)
Malawi
29.2% of children with uncomplicated malaria were subject to
medication error (Osterholt et al, 2006).
Nigeria
Out patient prescription common errors- over dosage (38%) and
under dosage (18.8%) (Oshikoya & Ojo, 2007).
Pakistan
Anaesthetic medication errors- under dosage & side effects/ drug
reaction. A total of 76% of the medication errors were classified as
preventable; 56% resulted from human error, whilst 19% was as a
result of system error (Khan & Hoda, 2005).
Malaysia
Common types of drug administration errors - incorrect time (34%),
followed by incorrect technique of administration (22%)
Intravenouse routes (21.3%) ( Chua et al, 2009).
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Types & Frequency of MAEs- A study in Malaysia
Hospital (2009)
1118
observations
127 errors
11.4%
error rate
Chua et al, 2009
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Effects of medical errors
Patients
(1st victims)
Health workers
(2nd victims)
• May suffer from illhealth, disability or
death
• Loss of confidence
& self esteem
• Loss of patient &
public trust
• Feelings of guilty,
shame &
embarrassment
• Lawsuits &
financial losses
• May experience
psychological &
financial problems
Institutions
• May face law suit,
imprisonment &
loss of job
“Honest error is to be pitied, not ridiculed.” ~ Lord Chesterfield
“Admit your errors before someone else exaggerates them.”
~ Andrew Mason
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Ethical and Legal Issues in Patient Safety
HIPPOCRATIC OATH
“To prescribe treatment
regimens for the good of
my patients according to
my ability and my
judgment and never do
harm to anyone".
Hippocrates 400BC
✓ Patients have a right to safe & effective care at all times (JCI, 2007)
✓ Healthcare professionals & Institutions owe a legal duty and
responsibility to providing safe care to their patients.
✓ Medical malpractice or negligent errors are acts of crime.
“Failure to disclose MEs compromise patients and societal trust”
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Strategies & Priorities to reduce MEs & promote
Patient Safety in Developing Countries
1. Laws, Policies and Guidelines to
promote patient safety
e.g Patient Safety Act- Denmark (2004),
USA (2005).
5. Incident Reporting Systems
Should be “ blame free”, confidential/ anonymous &
non punitive
6. Accreditation of Hospital
2. Stakeholders Involvement
It helps to improve safety & quality
(McFadden et al, 2006)
3. Creating Patient Safety Culture
Safety as a commitment & priority
4. Promotion of safe clinical practices
e.g “ Five Rights Principle” (5Rs), double
checking, correct diagnosis & prescriptions,
proper patient handovers
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“ Accredited hospitals reported improvements in;
reduction of medication errors, professional
credentialing…” (JCI, 2007)
7. Staffing, Education & Training of
Healthcare workers
Including training of pharmacists & drug vendors
e.g Kenya, Phillipines, Indonesia & Nepal
8. Improving Communication & Teamwork
9. Promoting research on patient safety
Conclusion
✓ MEs will continue to claim many lives silently in developing
countries, unless immediate attention and effort is made to
prevent this problem.
✓ In order to successfully win the war against MEs, strong
commitment and application of a comprehensive approach
are essential.
✓ Patient safety can only be achieved through a “bundle”
strategies.
“Learn from the mistakes of others. You can't live long enough
to make them all yourself”~ Eleanor Roosevelt
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Thank You!
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