LETTER TO THE EDITOR

Year : 2011  |  Volume : 24  |  Issue : 2  |  Page : 551

Controlling Errors to Promote Patient Safety

SM Khowaja
Karachi, Pakistan

Correspondence Address:
S M Khowaja
Flat #7, Al-Rahim View, Alyabad Colony, Block-8, FB Area, Karachi
Pakistan

Source of Support: None, Conflict of Interest: None

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PMID: 22081658

Dear Editor,



In a recent World Health Organization report, Sir Liam Donaldson, Chair of WHO Patient Safety, states that '…every year, tens of millions of patients worldwide suffer disabling injuries or death due to unsafe medical care'¹. Hospital errors are more and more frequent to the point of almost becoming the norm². Patients entrust their lives to healthcare professionals expecting cure and care, but sometimes the results can be tragic. What may be surprising is that patient safety is not just a problem in developing countries but is also an issue in the developed world². 

There is a wide range of categories of hospital errors; however, medication errors are reported to be the most common single preventable cause of patient injury³. Moreover, there could be many contributing factors, but communication, or lack of it, among healthcare professionals has been found to be one of the major causes leading to adverse events¹. Consequences of such errors range from no harm or minor injury to life threatening injury, disability and even death of the patient.

This significant burden of hospital errors can be reduced by adopting strategies at the individual, administrative and governmental level. At the individual level, one must ensure the right of the patient. The Agency for Health Care Research and Quality emphasizes that patients, for their part, must make sure that they know about their disease and the treatment they are receiving. Furthermore, they must raise questions if anything seems wrong to them⁴. They can certainly contribute in reducing negative and even deadly trends in hospital errors. No doubt, healthcare professionals are also responsible for keeping this right of the patient by ensuring shared knowledge and free flow of information to empower patients⁵. Healthcare professionals must be accountable in performing their duties through sound knowledge and critical thinking.

Leadership and administration must also take responsibility to respond to any errors taking place, which should be done through proper investigation and root cause analysis to determine both causes and consequences of errors. Also, sound policies need to be developed and implemented⁶. For instance, some hospitals have a policy of incident reporting so that timely action can prevent further problems as well as reduce lawsuits. Continuous monitoring, using internal and external audits, should take place on a regular basis. Additionally, there should also be a focus on continuing education for healthcare professionals. Last but not least, the government has the prime responsibility of ensuring that healthcare professionals have valid licenses to practice and must both make as well as timely modify policies to meet international quality standards.

In conclusion, reducing errors 'is not a question of pointing a finger at one staff member', rather it is about examining hospital systems at multiple levels in an effort to reduce and minimize the effects of errors'⁷.

Salima Muhammad Saleem Khowaja
Registered Nurse, Karachi, Pakistan

References

1. World Health Organization. Patient safety Research. WHO Patient Safety Research. 2009: WHO/IER/PSP/2009.10, p.1-3. Available from: http://whqlibdoc.who.int/hq/2009/WHO_IER_PSP_2009.10_eng.pdf

2. Medical News: Hospital error resulted in 17 cancer patients wrongly told they were clear. (Online). 2008, Aug 3. Available from: http://www.news-medical.net/news/2008/08/03/40483.aspx

3. Reinertsen JL. Let's talk about error: Leaders should take responsibility for mistakes. British Medical Journal. 2000; 320:730. Available from: http://www.bmj.com/content/320/7237/730.

4. Agency for Healthcare Research and Quality. 20 tips to help prevent medical errors. Patient Fact Sheet. 2000. Available from: http://www.ahrq.gov/consumer/20tips.pdf

5. Stencel C, Dobbins C. Preventing medication errors. National Academies Press. (Online). 2006. Available from: http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=11623

6. Brushwood, DB. Medication Errors. Case studies in medication error prevention. 2004; 26(4):1-20. Available online: http://www.wfprofessional.com/documents/April%202004.pdf

7. American Heart Association. Following protocols can reduce medication errors for heart, stroke patients. American Heart Association scientific statement. (Online). 2010. Available from: http://www.newsroom.heart.org/index.php?s=43&item=988