Even in high income countries, one in 10 patients experience some form of harm while receiving medical treatment. In some cases, these events can be serious, causing significant harm or even death.1
In critical care the percentage can rise to as much as 1 in 5.2
Despite the best intentions of healthcare providers, such adverse events occur in healthcare settings this rate of error and harm remains unacceptable.
“Patient safety must always be at the forefront of healthcare provision. We have a moral obligation to do everything in our power to prevent harm and provide the best possible care to those who need it,” says Dr DJ Hamblin-Brown, CEO at CAREFUL.
To reduce the risk of adverse events, it is clearly the responsibility of providers to address and manage patient safety risks – and to engage with the prevention strategies that will minimise the risk of harm, such as implementing best practises in clinical care, improving communication and collaboration within and between healthcare teams, and using technology to support their efforts where necessary.
One example of a patient safety initiative that has been implemented is the ‘Never Event’ programme. This programme aims to reduce the number of serious, largely preventable patient safety incidents and has been instrumental in reducing the number of adverse events in healthcare settings. ‘Never events’ “are serious incidents that are entirely preventable because guidance or safety recommendations providing strong systemic protective barriers are available at a national level”.
In addition to initiatives like the Never Event programme, healthcare providers must also be transparent about adverse events and work together to prevent similar incidents from happening in the future. This can be achieved through the implementation of open disclosure policies, where healthcare providers are encouraged to be transparent about adverse events and to work together to find solutions to prevent future harm.
Dr Hamblin-Brown and Ms Judi Ingram published a paper in 2018 demonstrating that sustained efforts by healthcare leaders can lead to a substantial reduction in never events and harm to patients.3
From this, and other research, we know that primary responsibility for reducing harm lies with practitioners and particularly leaders. But what about patients?
Using – as we often do in healthcare – the leading example of the airline industry, it’s clear that passenger safety is the responsibility of pilots, crew and the many ancillary staff adhering to, maintaining and updating safety designs and procedures. But we should also recognise that passengers are also expected to behave in ways that promote safe flying. Passengers are expected to behave appropriately in and around aircraft.
Without undermining the responsibility of providers, we should therefore also encourage patients, their family members and carers to take steps to ensure their own safety.
Some ways to do this can be to ensure they become informed about any medical treatments, asking questions, and — difficult though this can be — speaking up if they have concerns about their care.
Speaking up as a patient or relative in a healthcare setting can be immensely difficult given how anxious the situation can be. Practitioners therefore need to encourage a dialogue with their patients, and to be open to challenge and questioning. Given that many patients are anxious about their care, it’s important to give time for patients to become involved.
“As patients, we have a right to expect safe and effective care, but we must also acknowledge we have some responsibility to be involved in decisions about our own care and to take steps to ensure our own safety,” says Roohi Hamlani, Co-founder and Head of Patient Participation at CAREFUL.
In conclusion, patient safety is a crucial aspect of healthcare that should never be taken for granted. By implementing patient safety initiatives, being transparent about adverse events, and working together to prevent harm, healthcare providers and patients can work together to ensure that patients receive safe and effective care.
- Slawomirski L, Auraaen A, Klazinga N. The economics of patient safety: strengthening a value-based approach to reducing patient harm at national level. Paris: OECD; 2017. Accessed 26 July 2019: http://www.oecd.org/els/health-systems/The-economics-of-patient-safety-March-2017.pdf
- Panagioti M, Khan K, Keers RN, Abuzour A, Phipps D, Kontopantelis E et al. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ 2019; 366. doi: 10.1136/bmj.l4185
- Hamblin-Brown DJ, Ingram J. The Step-Up programme: Engaging all staff i patient safety. Journal of Patient Safety and Risk Management 23(5). doi: 10.1177/2516043518792180
