Ali Yawar Alam ( Regional Accreditation Coordinator & Director Project Management Office )
Professor Avedis Donabedian (physician and founder of study of quality in health care and medical outcomes research) reflects on the culture of patient safety and risk reduction with these golden words: "Health care is a sacred mission... a moral enterprise and a scientific enterprise but not fundamentally a commercial one. We are not selling a product. We don't have a consumer who understands everything and makes rational choices; and I include myself here. Doctors and nurses are stewards of something precious. Ultimately the secret of quality is love. You have to love your patient, you have to love your profession, you have to love your God. If you have love, you can then work backward to monitor and improve the system."1 Patient safety is the prevention of errors and adverse effects to patients associated with health care.2 Patient safety was defined by the Institute of Medicine as "the prevention of harm to patients."3 It is the reduction and mitigation of unsafe acts within the health care system, as well as through the use of best practices shown to lead to optimal patient outcomes.4 Patient safety is the sustained, proactive process of identifying, avoiding and rapidly resolving errors, omissions, miscommunications that could affect a patient's healing, health or well-being at any point, at any time, in any care setting.4 Risk is a probability/threat of damage, injury, liability, loss that is caused by vulnerabilities that may be avoided through pre-emptive action/s.5 Interaction of patients with health systems pose a threat to them mainly because of the; complex technology, intensely complex procedures, high demand on services, time pressure, high expectations from the service users, hierarchical by nature of training and responsibilities.5 There is a one in a million chance of a person being harmed while travelling by plane. In comparison, there is a one in 300 chance of a patient being harmed during health care.6 The latest data show that patient harm is the 14th leading cause of morbidity and mortality worldwide with about 43 million adverse events taking place world-wide during hospitalization.6 Statistics of adverse events and errors during hospitalization for Pakistan are not available. Culture of risk management or adverse event reporting does not exist in majority of public and private sector healthcare institutions in Pakistan.7 Risk management for healthcare entities (Public and private sector hospitals, Primary health care centers, laboratories, blood banks, nursing care centers, homecare) can be defined as an organized effort to identify, assess, and reduce, where appropriate, risk to patients, visitors, staff and organizational assets. Risk management in its best form may be to use it in a proactive manner in identifying and managing the risks.5 In Pakistan where a blame free culture or just culture of incident reporting (OVR) does not exist, it is extremely predictable that in most healthcare institutions, there is either no reporting or under-reporting of adverse events, errors, omissions, commissions and near misses. As a result this passive system of incident reporting is nonreliable i n our context as f ar as learnin g and improvements are concerned. One way to counter that is by Involving the leaders and staff in each department/discipline in healthcare institutions in Pakistan is to think proactively and get involved in Risk identification, risk analysis, risk evaluation and risk treatment/management.5 As this will be a pro-active exercise, there will be no issue of blame, fear of consequences or punitive action. Moreover, who could be more knowledgeable about the risks to patients in his/her area of work/department/discipline, than the staff working in that area. Handing over the responsibility of correcting the systems to the staff rather than the administration alone, will go a long way in boosting staff morale, confidence and promoting a culture of patient safety in the organization. This change will be practical, acceptable to all and sustainable in the long run, which is a highly desirable attribute of any change.
Risk management can be beneficial in the following contexts:5
1- Enterprise Risk Management (ERM): Comprehensive risk management of the organization from top down including financial and business viability.
2- Patient care (All clinical areas and clinical disciplines, labs, blood banks, Primary health care centres, nursing care centres, homecare)
3- Medical staff (Such as; credentialing, privileging, job description, employee Insurance, trainings, medical coverage)
4- Non-medical staff (Such as; job description, training, medical coverage)
5- Financial (Budgeting, cost-benefit and cost effectiveness analysis, Insurance coverage)
6- Managerial (Such as; organogram, Job descriptions, delegation of work)
7- Project risk management (Such as scope, time, cost, human resources, operational, procedural, technical, natural and political)
8- Facility Management and safety (Such as building safety, security of the facility, hazardous materials and waste disposals (HAZMAT), emergencies internal and external, fire safety, medical equipment maintenance plan and maintenance plan for each of the utility system.
Pakistan does not have a National health care Accreditation system/organization, National quality of care and patient safety indicators and organizational culture of patient safety and accountability in the majority of the healthcare entities.8 The country spends only 0.5-0.6% of GDP on health.8, As a result, there is huge potential for improvement in patient safety and risk reduction in healthcare entities in Pakistan. The leadership of the public and private healthcare entities in Pakistan has to gear-up their approach by applying themselves and empowering their staff to take up risk identification and risk management activities, as a result promoting patient safety and improving patient outcomes. It is the leadership to show the direction, provide training opportunities for the staff and providing the support required for risk management and other patient safety initiatives. Time is not far away in Pakistan (in sha Allah), when the hospitals will be ranked in terms of star rating and the customers will have their choice to select their place of care and the care-provider. A substantial raise in the GDP spending for health, strong National health policy and stringent monitoring by Federal Government and firm implementation & monitoring by Provincial Governments, will pave the way for a smarter and safer healthcare system in Pakistan.
Disclaimer: None to declared.
Conflict of interest: None to declared.
Funding Source: None to declared.
1. Newswise. 50 years ago this month, a new era in health care dawned. [Internet] 2016 Jul 22 [cited 2018 Aug 30] Available from: https://newswise.com/articles/50-years-ago-this-month-a-new-erain- health-care-dawned
2. World Health Organization. Patient safety. [Internet] 2018 [cited 2018 Aug 30] Available from: http://www.euro.who.int/en/healthtopics/ Health-systems/patient-safety
3. Institute of Medicine (US) Committee on Data Standards for Patient Safety; Aspden P, Corrigan JM, Wolcott J, et al., editors. Patient Safety: Achieving a New Standard for Care. Washington (DC): National Academies Press (US); 2004.
4. Khoja TA. Glossary of Patient Safety and Risk Management. Riyadh, Saudi Arabia: Executive Board of the Health Ministers' Council; 2014.
5. Alam AY. Steps in the process of risk management in healthcare. J Epid Prev Med 2016;2:118.
6. World Health Organization. 10 facts on patient safety [Internet] Updated 2018 Mar [cited 2018 Aug 30] Available from: http://www.who.i nt/feat ures/fac tfi les/pati ent_ safety/en/
7. Jafree SR, Zakar R, Zakar MZ, Fischer F. Assessing the patient safety culture and ward error reporting in public sector hospitals of Pakistan. Safety in Health 2017;3:10. https://doi.org/10.1186/s40886-017- 0061-x.
8. Shah M, Perveen S. State of healthcare quality and patient safety in Pakistan. Pak J Public Health 2016;6:1-4.