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EDITORIALS: Glyn Elwyn and Janet M Corrigan The patient safety story BMJ 2005; 331: 302-304 [Full text]

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Learning from the medical errors

Ediriweera B.R., Desapriya, Dr. Ian Pike   (9 August 2005)

Has the Patient Safety Story been told ?

Sharon L. Desmond   (15 August 2005)

How is the story told

Meindert van der Veer, Meindert van der Veer   (18 August 2005)

The patient safety story: the post-normal view

David R Ball   (27 August 2005)

The Australian patient safety story

Diane M McErvale   (27 August 2005)

How do we know if practice is safer?

Romi Haas   (5 September 2005)

Learning from the medical errors 9 August 2005
Ediriweera B.R., Desapriya, Research Associate V6H 3V4, Dr. Ian Pike Send response to journal: Re: Learning from the medical errors	Patient safety is receiving growing attention in developed countries in contrast to the less developed countries. We read with interest the recent BMJ Editorial by Elwyn, G., and Corrigan, M.J., (2005) on ‘The patient safety story’. (1) Although a number of measures to reduce errors were proposed, a key strategy involved the use of reporting systems to identify and learn from errors. (2) However a new survey of hundreds of executives running hospitals in six states in US finds a majority object to state laws requiring hospitals to report major and minor medical errors. If hospital leaders continue to harbor negative views of reporting, it is unlikely that state mandatory reporting systems will be highly successful in the long run.(2) Promoting patient safety is a national priority. Health-care providers' own discussions of adverse events can be a good source of data for proactive error prevention. Safe medical practices can be more easily achieved if medical staff recognizes the benefits of reporting, discussing, and learning from errors. Practice safety relies on a greater safety culture within organizations. (3) But overall, error-reduction in health care often continues to blame individuals, rather than examining systems, hence often fails to detect or correct underlying systems failures when errors occur. One important problem in assessing the frequency of errors is that we are deeply immersed in a blame culture, so it is hard to persuade people to report them. If we are to learn from mistakes then we need to know about as many as possible so that corrective action can be taken. This requires a cultural change and sensitive handling of the individual making the report. Capacity of reporting analyzing and learning from experience is still seriously hampered by fear of professional liability. (2) The risk of litigation and costly settlements has further discourage disclose information about errors. Changing the culture of medicine to increase reporting of errors is central to current efforts to reduce future error in health care. To change the culture of medicine we need to change legal culture of litigation. Improvements should be made to our medical liability system - improvements that can substantially reduce meritless claims and defenses, enhance opportunities to resolve claims fairly without protracted litigation and make the system fairer for doctors and patients alike. All parts of the health care system – lawyers, doctors, insurers and patients have a responsibility to help make the health care system more affordable. Action to reduce medical errors should not include punitive actions against the individuals who make the mistakes, but rather action on the systems in which the mistake occurred (4, 5). References: (1). Elwyn, G., Corrigan, M.J., The patient safety story. BMJ 2005; 331;302-304 (2). Weissman, J.S., Annas, C.L., Epstein, A.M., et al; Error reporting and disclosure systems. JAMA 2005: 293 (11) 16 (3). The Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington: National Academy Press; 2001. (4). Holbrook, J., The criminalization of fatal medical mistakes. BMJ 2003; 327:1118-1119. (5). Desapriya, E., Canadian Adverse Events Study. CMAJ 2004; 171 (8):834 Competing interests: None declared
Has the Patient Safety Story been told ? 15 August 2005
Sharon L. Desmond, Practice Manager/ Quality Co-ordinator St Vincent's Hospital, Melbourne, Australia Send response to journal: Re: Has the Patient Safety Story been told ?	According to Elwyn and Corrigan, the patient safety story “Has been told, now it is time to make practice safer.”(1) The application of safe clinical practice is a cornerstone of the Quality tale. The narrative has only just begun! And, along the way, we must share our successes. The new website www.saferhealthcare.org.uk is a forum in which we can do this – internationally. Continuous quality improvement (CQI) is now a germane component of health care provision.(1) As in the UK and the USA, agencies have been established in Australia to promote, implement and oversee safety in health. The state governments, the Australian Council for Safety and Quality in Health Care (ACSQHC) and the Australian Council on Healthcare Standards (ACHS) have been pivotal in instituting error reporting in this country.(2) Furthermore, these bodies have been vocal in calling for a paradigm shift in the culture of medical blame; from one focused on individuals, to one that analyses and corrects deficiencies in operational systems. The transition to institutional focus on error identification and reduction is not complete ‘Down Under’. Of interest however, health care facilities are increasingly adopting proactive clinical risk management (CRM) strategies. Practitioners are being ‘re-educated’ regarding ‘blame’ through their workplaces and professional networks. Currently, a substantial case of systems errors is being investigated at Bundaberg Hospital in Queensland. Akin to the Bristol Royal Infirmary scandal, it is anticipated that this case will further highlight the centrality of process failure in adverse events. Around the globe, medical errors remain at unacceptably high levels.(3) Therefore, the most pressing question in the patient safety story is; how do we embed CRM in “…everyday clinical behaviour.”(1) An urgent, creative approach in needed. Top-level executives must cultivate a culture of safety in their health care entities. Simultaneously, clinicians and managers must to work together to ensure practical systems are developed, implemented, and evaluated. By working jointly on quality and safety issues, clinicians and managers have the opportunity to improve their “…danse macabre…”.(4) It is fundamental in the continuing quality chronicle that clinicians and managers liaise cooperatively in the development of electronic data systems, so that the much lauded epidemiological quality potential can be practically harnessed in safety and risk reduction.(5) Finally, as the patient safety story continues to unfold, lessons must be shared. I look forward to the collegiate sharing of information on the ‘saferhealthcare ‘website. Sharon Desmond, BA(Hons), Grad Dip, RN(Div 2), Cert Pract Man, MAAPM Practice Manager / Quality Co-ordinator St Vincent's Hospital, 41 Victoria Parade, Fitzroy 3065, Australia sharon.desmond@svhm.org.au References: (1) Elwyn, G., Corrigan, M.J., The patient safety story. BMJ 2005,331; 302-304 (2) www.safetyandquality.org and www.achs.org.au (3) McNeil, JJ., Ogden K., Briganti, E., Ibrahim, J.E., Loff, B., Mjoor, J.W.,Chapter 2:Literature review. Improving patient safety In Victoria hospitals. Victoria: Department of Human Services, 2000: 5-21. (4) Degeling, P., Maxwell, S., Kennedy, J., Bole, B., Medicine, management and modernisation; a “danse macabre’?. BMJ 2003,326; 649-652 (5) Iezzioni, L.I., Assessing quality using administrative data. Ann Intern Med 1997;127:666-674 Competing interests: None declared
How is the story told 18 August 2005
Meindert van der Veer, Director of Medical Services Portland District Health, Portland, Victoria, 3305 Australia, Meindert van der Veer Send response to journal: Re: How is the story told	Elwyn and Corrigan refer to the Harvard study and the Quality in Australian Health care study and state that the patient safety story “Has been told; now it is time to make practice safer”(1). Though both the Harvard study and the Quality in Australian Health Care Study have demonstrated a significantly high rate in errors, there are aspects of the studies that need to be highlighted. The Harvard study has been shown to under report error rates, due to the study design.(2) One of the points raised by Andrews et al is that the study relied on errors reported in medical records. Medical record reviews have been shown to have its limitations in reporting error rates due to incompleteness, lack of accuracy and illegibility to name but a few.(3) The Australian study incorporated a preventative focus and had a broader quality of care approach.(4) Whether this can account for the higher error rates reported in this study is not entirely clear. The study was also conducted 10 years after the Harvard study, during which time there had to be advances in care delivery. Despite these differences in the studies, the fact that adverse events occur cannot be denied. However it is also true that though adverse events get reported, most accidents, slips, violations or near misses do not as often get reported in the media. "To err is Human" was targeted at the public and as pointed out by Elwyn and Corrigan has led to increased media participation at the time.(5) That interest in Health care related matters has not waned and headlines on adverse events are a frequent occurrence. How is this told though? Reporting on medical matters is often biased and the standard of reporting varies significantly.(6) The Australian Press Council promotes a conservative, careful approach to health and medical reports.(7) This would indicate that on reporting on adverse events, a well-balanced view should be portrayed, underpinned by the quality principle of, system error blame rather than personal blame. Too often though the personal blame is highlighted by sensationalist headlines. Efforts to rectify this have met with resistance from journalists(8), seeing this as a personal attack on their integrity. To tell the story accurately: “Each side needs to appreciate the other’s agenda”(9). Cooperation between media and health care organisations is needed to ensure the quality drive continuous in a transparent and open way. As Elwyn and Corrigan rightly point out, our efforts should now be on the promotion of the safety culture by rectifying system errors. This will certainly be affected by how the story is told. Meindert van der Veer MB.ChB FRACGP MRACMA AFACHSE Director of Medical Services Portland District Health, Bentinck street, Portland, Victoria, 3305 mvanderveer@swarh.vic.gov.au References: 1 Elwyn, G., Corrigan, M.J., The patient safety story. BMJ 2005,331: 302 - 304 2 Andrews LB, Stocking C, Krizek T, et al. An alternative strategy for studying adverse events in medical care. Lancet 1997; 349: 309-313 3 Donabedian A. The quality of care: how can it be assessed?. JAMA 1988; 260: 1743-1748 4 McNeil JJ, Ogden K, Briganti E, Ibrahim JE, Loff B, Majoor JW. Chapter 2: Literature review. Improving patient safety in Victorian hospitals. Victoria: Department of Human Services, 2000: 5-21 5 Elwyn G, Corrigan MJ, The patient safety story. BMJ 2005; 331: 302 - 304 6 Van der Weyden MB, Armstrong RM, Australia’s media reporting of health and medical matters: a question of quality MJA 2005; 183(4): 188-189 7 Australian Press Council. General Press Release No 245. (April 2001). Reporting guidelines. Available at: http://www.presscouncil.org.au/pcsite/activities/guides/gpr245.html (accessed Aug 2005) 8 Smith DE, Wilson AJ, Henry DA, Monitoring the quality of medical news reporting: early experience with media doctor, MJA 2005; 183(4): 190-193 9 Herman JR, Morgan JAT, Medical news reporting: establishing goodwill and cooperation, MJA 2005; 183(4): 195-196 Competing interests: None declared
The patient safety story: the post-normal view 27 August 2005
David R Ball, Consultant Anaesthetist Dumfies and Galloway Royal Infirmary , Dumfries, UK. DG1 4AP Send response to journal: Re: The patient safety story: the post-normal view	Increasing recognition that patient safety has a key role in health care matches the wider changes in society from the "normal" to the "post- normal" scientific viewpoint. The term "normal science" was introduced by Thomas Kuhn in his book "The Structure of Scientific Revolutions" [1], which also introduced the concept of "paradigm shift". Normal science is concerned with the knowledge and power of what we do. The post-normal view is also concerned with these, but also with the safety and uncertainty of our work [2]. Explicit recognition of the importance of, as well as the tensions between the dimensions of knowledge, power, safety and uncertainty represents a "paradigm shift" in how we collectively think about healthcare. References 1 Kuhn TS. The structure of scientific revolutions. Chicago: Chicago University Press, 1970. 2 Funtowitz SO, Ravetz JR. Science for the post-normal age. Futures 1993;25:739-55. Competing interests: None declared
The Australian patient safety story 27 August 2005
Diane M McErvale, Operating Suite Manager Cabrini Health Malvern Vic Australia 3123 Send response to journal: Re: The Australian patient safety story	The Australian patient safety story The BMJ Editorial by Elwyn,G. and Corrigan,M.J. (2005) on ‘The patient safety story’ highlights the prominence given to safety in healthcare occurring in the UK and USA.(1) I believe the Australian story also needs to be told. The Australian patient safety story gained momentum with the publication of the Quality in Australian Health Care Study, which found that 16.6% of hospital admissions were associated with an adverse event. (2) In an effort to develop a national strategy for improving safety and quality in healthcare, the Australian health ministers provided funding to form the Australian Safety and Quality Council. This was formed in 2000 with funding until 2006.(3) The final Safety and Quality Council report presented in July 2005 highlighted several achievements – most notably the development of procedures to improve surgical safety as well as a national system for reporting, collection, analysis and correcting the causes of serious adverse events.(4) Of major concern to me as a clinical manager are the results of the government review of healthcare which found that despite the initiatives created by the Australian Safety and Quality Council, there is little evidence that Australia has made any measurable progress in improving safety and quality since the 1995 Quality in Australian Health Care Study.(5) As Elwyn and Corrigan state ‘the next step is to embed safe practice into everyday clinical behaviour’.(1) I believe the Australian patient safety story will only improve if the new body announced by the Australian health ministers is given the power to develop national healthcare standards and enforce the implementation of these standards.(4) References: (1) Elwyn, G., Corrigan, M.J., The patient safety story. BMJ 2005,331; 302-304. (2) Wilson RM, Runciman WB, Gibberd RW et al. The Australian Quality in Health Care Study. MJA 1995; 163: 458-471. (3) www.safetyandquality.org (4) www.health.gov.au/internet/wems/publishing (5) www.theaustralian.news.com.au/printpage: Inertia on healthcare standards, 20 aug05 Competing interests: None declared
How do we know if practice is safer? 5 September 2005
Romi Haas, Physiotherapist Southern Health, Kingston Centre, Cheltenham 3192 Australia Send response to journal: Re: How do we know if practice is safer?	In agreement with Elwyn and Corrigan’s(1) editorial, the patient safety story has indeed been told; it is now time to make practice safer. However, in order to determine how best to achieve this and whether we are successful, it is of utmost importance to implement accurate, timely and comparable methods of patient safety data. While Elwyn and Corrigan(1) effectively highlight the unacceptably high rate of adverse events in health care internationally (it is frightening that we are statistically more likely to die from being hospitalised than from a motor vehicle accident!), the accuracy of a baseline error rate close to 10% is questionable as is the epidemiology of such adverse events. The Harvard Medical Practice Study and Quality in Australian Health Care Study referred to in this editorial cite adverse error rates of 3.7% and 16.6% per hospitalisation respectively(2). However, it seems this variation can at least be partially explained by differences in the study methodology, purpose and data sources utilised. It is therefore clear that more standardised methods of analysing adverse error rates are required if we are to accurately compare intra and inter-organisation rates. To maximise the utility of patient safety data, Boxwala et al(3) propose a common reference data model encompassing data from multiple sources and the use of standardised terminology. Although this suggestion is theoretically sound, gaining consensus on terminology and achieving representation of patient safety data that is flexible enough to encompass multiple purposes may be a tall order in practice. Therefore, determining key methods of safer practice and assessing its success will be dependent upon the effective management of large volumes of data. In fact, information technology has been identified as an integral component to promoting quality, minimising human error and achieving accurate, comparable and timely representation of patient safety data(4). References: (1) Elwyn G, Corrigan M.J. The patient safety story. BMJ 2005; 331:302-304. (2) McNeil JJ, Ogden K, Briganti E, Ibrahim JE, Loff B, Majoor JW. Chapter 2: Literature review. Improving patient safety in Victorian hospitals. Victoria: Department of Human Services, 2000: 5-21. (3) Boxwala AA, Dierks M, Keenan M, Jackson S, Hanscom R, Bates DW, Sato L. Organization and Representation of Patient Safety Data: Current Status and Issues around Generalizability and Scalability. Journal of the American Medical Informatics Association 2004; 11(6):468-478. (4) Marin HF, Improving patient safety with technology. International Journal of Medical Informatics 2004; 73(7-8):547-550. Competing interests: None declared