Patient safety lessons from the world’s expertsBMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k5211 (Published 27 December 2018) Cite this as: BMJ 2018;363:k5211
All rapid responses
I agree with the report by Jaqui Wise that patient engagement is critical to patient safety. Patient care will only be at minimal risk if all relevant information is available when decisions are being made. Patients do not have technical understanding of risks, but they may have important information which if not disclosed may lead to preventable risk.
A culture of openness is laudable but it may bring its own problems. Whilst it is difficult to see how secrecy could contribute to patient safety, there are broader issues.
Patients may not want to disclose information about illegal or culturally unacceptable behaviour, unless they are confident that their information is closely protected. Yet disclosure may be necessary where there are untoward incidents.
The problem seems to turn on the definition of secrecy and of confidentiality in the relevant context. These concepts need to be defined carefully, agreed locally and made available to staff, patients and when appropriate to their carers.
Before relying on patient advocates to suggest improvements to be made to ensure their safety, there needs to be some reassurance for patients that they will not be penalised, exposed or judged for disclosing relevant information such as illicit drug use, or immigration status.
Competing interests: No competing interests
The BMJ has highlighted the challenges facing global efforts to improve patient safety at the health care level and the need to learn from global exemplars. Although Mike Durkin at Imperial College London states that “Patients can drive the agenda for change—more so than professionals” regarding thromboembolism,1 much more is needed to improve safety at the health care level globally; a holistic approach is required starting at the very top.
Any holistic attempt to improve patient safety at the health care level on a national or global scale should involve the following:
COMMITMENT TO PATIENT SAFETY AND ENSURING COMPLIANCE
Improvement in patient safety at national level starts with commitment to a comprehensive, effective national program for patient safety improvement starting at the top level of government and the medical profession and its regulatory bodies. Such a program should set out the national goals, policies, strategies regulations, guidelines, and specific rules, and establish the training, monitoring and regulatory bodies. Commitment alone is not enough without ensuring adequate monitoring, compliance, enforcement and achievement of desired goals.
TRAINING ON PATIENT SAFETY STARTS IN MEDICAL SCHOOLS
Commitment to patient safety starts with mandatory training of students at all medical, nursing, pharmaceutical, and allied schools that are committed to health care of patients. The WHO has developed the Patient Safety Curriculum Guide for Medical Schools that can be implemented in any medical school irrespective of geography or culture. Many medical schools around the world have integrated the curriculum into their teaching and learning materials.2
PATIENT SAFETY MUST BE TOP PRIORITY OF MEDICAL TEAM IN ALL HEALTH FACILITIES
Commitment to patient safety must be made top priority at all health facilities. Improving patient safety requires establishing a culture of openness where issues relating to patient safety raised by patients or medical staff alike is addressed in a protected honest open environment where neither the complainant who may be a patient or doctor would feel threatened, penalized, punished or face adverse consequences because of the complaint.
It must be the ongoing culture that the health care team is collectively responsible for ensuring patient safety. Each member of the team is expected to play his role by ensuring that patient safety is a routine part of daily clinical practice by all members of the health care team in the health facility. In the event a team member becomes of concerned on about practice of a colleague that appears to compromise patient safety, this matter should be brought to the attention of the health care team and addressed in a spirit of openness within the team and addressed appropriately. The objective should be correction and training where necessary for prevention of future occurrences rather than find fault or delivery of punishment. It must be a win-win situation where all benefit from this cultural process. Training on patient safety must be practiced and addressed by the health care teams as part of normal daily health care with enhancement through training, engagement, and reinforcement.
WHISTLE BLOWERS (WBs) NEED PROTECTION
There is, sadly, a lack of culture of openness in rich countries; this is practically non-existent in the middle and low income countries. Patients and staff have reservations in raising concerns because there is no culture of openness; people who have the courage to speak up about patient safety concerns are vilified. WBs are derided as “snitches, troublemakers, and backstabbers”. Staff records were being used to blacklist whistleblowers in the NHS. WBs are discriminated against when they seek re-employment in the NHS after making disclosures about patient safety.3 ‘Sir Robert Francis found a number of people struggled to find employment in the NHS after making disclosures about patient safety. He warned of a culture of ‘fear, bullying and ostracisation’ within the NHS that punished doctors and nurses who exposed failings. He said whistleblowers were derided as ‘snitches, troublemakers and backstabbers’.3
WBs are not protected adequately as the law has failed to provide them the justice they merit even in a country with an enviable health service. Middle income and low income countries should not be deterred as success comes from commitment and openness to ensuring safety with prioritization and cost-cutting measures that are justified with the available resources. There is a need for change in culture where whistleblowing becomes the accepted norm of daily life. It needs to be incorporated as part of daily work of the health care team, to identify and review all patient safety concerns on a non-blame-non-punishment basis, as a corrective and not punitive measure, with shortcomings addressed through intervention and training.
WB’s COMPLAINT SHOULD BE ADDRESSED BY INDEPENDENT BODY
Sadly, institutions cannot be relied to be impartial when their own administration and staff are under the microscope. What is needed is an impartial independent body to receive and process all concerns about the health care service expressed by patients, nurses, and doctors. An institution should not be permitted to investigate itself. Professional and financial wellbeing of whistleblowers should be monitored and protected by law by an independent body overseen by the judiciary. A system of rewards for complaints that when addressed lead to improved patient safety in the health service would help the process.
DRUGS WITH SERIOUS ISSUES THAT COMPROMISE PATIENT SAFETY
Prescription drugs continue to escalate in price and are a major expenditure of health care services. Some new drugs heavily marketed by the industry have serious drug safety issues, and controversies have become more common. Obomsawin has raised concerns about the promotional and safety practices of the mainstream drug industry whose influence on the medical profession’s prescribing is widely recognized. Academic researchers were paid to put their names on published articles prepared and written by company-paid medical writers. This has negative impact on patient safety. Drug ingredients and drugs imported from overseas are rarely quality control checked by the domestic regulators and the major drug companies themselves don’t bother to run quality control checks on the drugs imported from China and other countries.4
These are issues of serious import that need to be addressed at national and global levels as they impact negatively on patient safety.
1. Jacqui Wise. Patient safety lessons from the world’s experts. BMJ 2018;363:k5211 doi: 10.1136/bmj.k5211 (Published 27 December 2018).
2. Walton M, Woodward H, Van Staalduinen S, Lemer C, Greaves F, NobleD, Ellis B, Donaldson L, Barraclough B, for and on behalf of the Expert group convened by the World Alliance of Patient Safety, as Expert Lead for the Sub-Programme. Republished paper: The WHO patient safety curriculum guide for medical schools. Postgrad Med J 2011; 87: 317–321. 4 Journal of the Royal Society of Medicine Open 9(11).
3. Sarah Knapton. NHS whistleblowers will get compensation if blacklisted by health service. The Telegraph. News/Science, 20 March 2017. Accessed https://www.telegraph.co.uk/science/2017/03/20/nhs-whistleblowers-will-g... on 8 January 2018.
4. Raymond Obomsawin. Compromise in the Pharmaceutical Industry. Sep 1, 2011. Accessed 8 January 2019.
Competing interests: No competing interests
The hidden patient safety problem
To the Editor,
While the valuable points raised in the report are targeting the heart of patient safety and remind us of the importance of building safety into the system and developing a transparent culture of safety, thinking about potential hazards before they become adverse events, and the role of leadership in facilitating the implementation of policies, little is discussed about medication errors in community pharmacies.1
We can see that most policies and regulations about patient safety are targeting initiatives to reduce hospital related errors and ensuring safety of patients in the inpatient settings, and little effort has been made in the settings outside the hospital particularly in relation to medication errors in the community.2 Considering the progressive increase in pharmacy visits and the number of medications dispensed annually, one could realize the size of such problem.3
Searching the literature, we find relatively few studies about errors in medications dispensed by community pharmacists, in the meantime there are limited or no policies in some countries about management and report of medication errors.4 The problem gets worse in countries were medications could be supplied by pharmacists to patients and their relatives without a prescription; how these errors could be traced, managed or reported will definitely not just compromise patient safety but raise questions about the breadth and depth of this problem and concerns about “a hidden patient safety problem” totally ignored in some communities.
Professor Samy Azer
Professor of Medical Education
King Saud University
1. Berrier K. Medication Errors in Outpatient Pediatrics. MCN Am J Matern Child Nurs. 2016 Sep-Oct;41(5):280-6. doi: 10.1097/NMC.0000000000000261.
2. Hardenbol AX, Knols B, Louws M, Askari M, Meulendijk M. Usability aspects of medication-related decision support systems in the outpatient setting: A systematic literature review. Health Informatics J. 2018 Nov 30:1460458218813732. doi: 10.1177/1460458218813732. [Epub ahead of print]
3. Koyama T, Onoue H, Ohshima A, Tanaka Y, Tatebe Y, Zamami Y, Shinomiya K, Kitamura Y. Trends in the medication reviews of community pharmacies in Japan: a nationwide retrospective study. Int J Clin Pharm. 2018 Feb;40(1):101-108. doi: 10.1007/s11096-017-0559-7. Epub 2017 Nov 30.
4. Schumacher PM, Neininger MP, Kaune A, Bertsche T. Counseling patients on correct drug handling in German community pharmacies: experiences and opinions of pharmaceutical staff. Int J Clin Pharm. 2018 Nov 29. doi: 10.1007/s11096-018-0757-y. [Epub ahead of print]
Competing interests: No competing interests