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Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis

BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l4185 (Published 17 July 2019) Cite this as: BMJ 2019;366:l4185

Linked editorial

Preventable harm: getting the measure right

Patient safety prevention or mitigation, lessons from studies: A good question raised, too many answers needed! Re: Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis

Patient safety prevention or mitigation, lessons from studies: A good question raised, too many answers needed!
Re: Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. Panagioti M: BMJ 2019;366:l4185. doi: 10.1136/bmj.l4185.

Today, a big public health challenge we must face is understanding and mitigating preventable patient harm. Harmful patient incidents have become a large financial burden for the fragile healthcare system and a bad experience for patient perceptions with physicians, which threaten the relationship between patients and clinicians and increase the practice of defensive medicine (1). This systematic review and meta-analysis by Panagioti M et al (2) reported that the pooled prevalence for preventable patient harm was 6% and a pooled proportion of 12% of preventable patient harm was severe or led to death. Furthermore, incidents related to drugs (25%) and other treatments (24%) accounted for the largest proportion of preventable patient harm (2).
The good news of this study is that “half of patient harm is preventable” along with the bad news is “less evidence is available for specific medical specialties” (2). How to benefit the most? As a doctor major in cardiology, the key point is to find the vulnerable patients and treat them with available evidence-based medicine and technologies. Harmful patient incidents widely exist in medical and health care system and some of them are actually hard to be completely avoided. Thus vulnerable patients detection, risk stratification and precision medicine implementation are a round continuum in the cardiovascular disease management. In the cardiovascular system, having titin-truncating variants was associated with a higher risk of receiving appropriate implanted cardioverter defibrillator (ICD) therapy for fibrillation or anti-tachycardia pacing (3). Even so, other patients who implanted an ICD or a CRT-D and experience an improvement of left ventricular function during follow-up, appear still to be at risk of major ventricular arrhythmias (4), not to mention there was a significant residual risk of appropriate implantable ICD therapy in the second generator life even among patients with advanced age and with a full prior generator period without any appropriate ICD events (5).
Fortunately, a couple of technologies including checklists, structured communication, scripted rounding, and electronic alerts have already been used to manage risk of harm incurred to patients. Even in the current healthcare system, these technologies are now deeply sedimented in managerial and professional discourses (6). The commitment to create a continuously improving culture of safety is imperative to optimize patient care and their outcomes. With an improved culture of safety, errors can be reduced and the overall progression of healthcare quality can be realized (7).
As stated in the study by Panagioti M et al (2), the heterogeneity of study methods and contents do have great impact on the interpretation and utilization of their conclusions. The heterogeneity behind these studies or literatures at least includes the following: assessment methods, harm severity definition, participants from different countries with diversified economic and health care quality status, participants from children, adults to older adults of in- and outpatients, different settings from primary care, emergency units to internal or surgical departments, different etiology from cancer, cardiovascular disease, trauma, behavior, psychiatry to drug usage, medical management as interventional or surgical procedures and so on. What we should do now? Yes, getting the measure right (8)! Obviously, more RCT trials focused on these heterogeneities are needed and too many new problems have already appeared!
Thank you for considering our views.

Dr. Zhu Yanrong
MD phD Chen Zhong (zhongchen7498@hotmail.com)

Department of Cardiology, Affiliated Sixth People’s Hospital East, Shanghai Jiao Tong University, Shanghai University of Medicine and Health Sciences, No. 222 Huanhu Xisan Road, Shanghai 201306, P.R.China
July 28, 2019
Competing interests: no competing interests.

Reference:
1. Lyu HG, Cooper MA, Mayer-Blackwell B, et al. Medical Harm: Patient Perceptions and Follow-up Actions. J Patient Saf 2017;13(4):199-201. doi: 10.1097/PTS.0000000000000136.
2. Panagioti M, Khan K, Keers RN, et al. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ 2019;366:l4185. doi: 10.1136/bmj.l4185.
3. Corden B, Jarman J, Whiffin N, et al. Association of Titin-Truncating Genetic Variants With Life-threatening Cardiac Arrhythmias in Patients With Dilated Cardiomyopathy and Implanted Defibrillators. JAMA Netw Open. 2019;2(6):e196520. doi: 10.1001/jamanetworkopen.2019.6520.
4. Artico J, Ceolin R, Franco S, et al. ICD replacement in patients with intermediate left ventricular dysfunction under optimal medical treatment. Int J Cardiol 2019. pii: S0167-5273(19)32357-5. doi: 10.1016/j.ijcard.2019.06.072. [Epub ahead of print]
5. Ruwald MH, Ruwald AC, Johansen JB, et al. Incidence of appropriate implantable cardioverter-defibrillator therapy and mortality after implantable cardioverter-defibrillator generator replacement: results from a real-world nationwide cohort. Europace 2019. pii: euz121. doi: 10.1093/europace/euz121. [Epub ahead of print]
6. Hutchinson M, Jackson D, Wilson S. Technical rationality and the decentring of patients and care delivery: A critique of 'unavoidable' in the context of patient harm. Nurs Inq. 2018;25(2):e12225. doi: 10.1111/nin.12225.
7. Lawson C, Predella M, Rowden A. Assessing the culture of safety in cardiovascular perfusion: attitudes and perceptions. Perfusion 2017;32(7):583-590. doi: 10.1177/0267659117699056.
8. Irene Papanicolas, Jose F Figueroa. Preventable harm: getting the measure right. BMJ 2019; 366: l4611

Competing interests: No competing interests

28 July 2019
Chen Zhong
Chief Physician
Yanrong Zhu
Department of Cardiology, Affiliated Sixth People’s Hospital East, Shanghai Jiao Tong University, Shanghai University of Medicine and Health Sciences, P.R.China
No. 222 Huanhu Xisan Road, Shanghai 201306, P.R.China