Wednesday, October 14, 2009

Above all do no harm; but what if the harm is unintentional?

Ever since the IOM's infamous report in 1999; To Err is Human, there have been numerous reports of both medical and medication errors. In my frequent presentations on Medication Safety, I have talked and educated about quite a few of them. In most cases, a root cause analysis was performed along with system analysis as well as individual staff duties and performances. Various legislative recommendations have been made, including the AHRQ list of "never events". The underlying emotion in all the cases that I reviewed was both sympathy and guilt by the individuals involved in these cases. I am quite sure, as most of you will agree with me, that no one goes to work planning to make a medication or medical error. Regardless of what discipline we are specialized in, we are health care workers. We all embrace the Hippocrates oath and want to take care of our patients, want to do a good job, so that at the end of our work we go home happy, content and with a good conscience.

Unfortunately we are seeing more "criminalization of health care", as David Marx puts it. The human error concept of errors is still taught, preached, but alas not practiced much anymore. These well meaning professional individuals, that were for so long providing "quality patient care" are now being penalized and in some cases convicted and sentenced with corresponding jail time. While I am sure many of us cannot even begin to imagine the horror, pain and suffering of the families of the patients, however penalizing individuals for human error caused due to system failures, breakdowns in communication and uncontrollable human factors, will not solve the problem. Rather in my humble opinion, will create a bigger one. Dr. Cohen has already eluded to it in his excellent article :

"An injustice has been done: Jail time given to a Pharmacist who made an error"- ISMP.

On the other hand, when I read about the efforts of the Josie King Foundation and the Quaid Foundation, not only am I deeply humbled, but proud as well. This is our nation, our society, our communities, that come together in times of despair and tragedy, and work together to ensure that the same mistakes are not repeated again. That no other child or family should have to suffer in silence again. The Josie King Foundation helped create a condition H in hospitals, that allows family members to alert caregivers when they are concerned about the health of the patient. The Quaid foundation is working with companies and health care quality organizations to ensure proper labeling of drugs. There are many more stories out there of families that came together and are joining hands with us, the health care workers, to ensure patient safety.

That is what we hope to achieve, make a safer health care system for both our patients and caregivers.

When David Marx introduced his concept of Just Culture, I felt liberated! At last, there is a system that will be more proactive than reactive. However, I too, much like Dr. Cohen, am becoming more concerned about these convictions. The results will most likely a decrease in error reporting for fear of reprisals; why report if we are going to lose our jobs, livelihood, after all nothing has happened to the patient yet. My question is, are we then going to wait for something to happen to another patient or are we going to help create a culture of trust among both patients and caregivers? As David Marx wisely put it, we are creating a "culture of blame"-how are we ever going to master a culture of patient safety?

Hence, safety voyagers, here is my first attempt at writing, recognizing the partnership of our health care workers AND our patients..

We are one!

Monday, October 12, 2009

Welcome Aboard Safety Voyagers!

While there are many blogs and sites discussing the need and importance of patient safety, I would like to offer a fresh approach to it by including the need to recognize a systems approach to both patient and caregiver safety along with prevention of errors.

The Just Culture concept by David Marx and the Human Culpability decision tree by James Reason are excellent tools for us to merge these two crucial value chains in the health care field. I hope we can all benefit from this interface and welcome all and any comments as well.

Stay Safe!!

“It must be considered that there is nothing more difficult to carry out, nor more doubtful of success, nor more dangerous to handle, than to initiate a new order of things”
                                                                                               Nicolo Machiavelli 1469-1527