Intended for healthcare professionals

Feature Quality improvement

Patient safety lessons from the world’s experts

BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k5211 (Published 27 December 2018) Cite this as: BMJ 2018;363:k5211

Global efforts to improve patient safety need holistic global and national commitment

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.

References
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

08 January 2019
Davendralingam Sinniah
Professor
MAHSA UNIVERSITY
Bandar Saujana Putra, Selangor, Malaysia