Promoting patient safety in Bhutan: Challenges and priority strategies for accelerating progress

Patient safety is a fundamental principle of quality health care. In Bhutan, which is a resource poor nation, improving patient safety in the health care context is a challenge. Bhutan requires sound patient safety policies and strategies to mitigate safety issues in the health care system. Drawing upon the available literature on patient safety in Bhutan and the author's own experience, this paper attempts to explore the challenges that the Bhutanese health care system is facing in terms of promoting patient safety. Based upon the challenges identified, this paper offers a roadmap to move forward—ie, suggestions on how Bhutan could promote patient safety.     

Assessing the impact of hospital mergers and acquisitions on safety culture with proactive risk assessments

Hospitals seeking to understand patient safety strengths and vulnerabilities in the context of mergers/acquisitions benefit more from a third-party perspective than from a limited internal process. A well-structured and highly-inclusive risk assessment—involving a broad cross-section of interviews—can be key to a successful transition of optimal health care safety during organizational changes.     

From To Err Is Human to Improving Diagnosis in Health Care: The risk management perspective

The publication of To Err Is Human in 2000, followed by Crossing the Quality Chasm in 2001, marked a watershed in patient safety. The Institute of Medicine (IOM) reports intensified the focus on patient safety and demanded a redesign of the healthcare system to improve quality and safety. Since publication of these reports, the focus has been on improving processes—those methods of healthcare delivery prone to failure and errors. Recently, there has been a concerted and sustained drive to add cognitive (diagnostic) errors to the focus. The recent publication of the IOM's Improving Diagnosis in Health Care has expanded the focus on patient safety and quality improvement. A new focus on diagnostic errors augments rather than replaces the previous focus. In this article, the authors offer a brief review of To Err Is Human and Crossing the Quality Chasm to lay a historical foundation. They then discuss a transition into the focus on diagnostic errors and summarize the latest recommendations from Improving Diagnosis in Health Care. This collated synthesis of 3 powerful IOM reports should guide risk managers and other healthcare personnel as they strive to improve every aspect of healthcare delivery.     

Special considerations accompany the ‘gift of life’

Patient safety practices for organ and tissue donors — as well as recipients — must be understood by health care providers to combat medical error. This article discusses how regulatory and accreditation bodies are doing their part to reassure the public that there are strict rules, criteria and provisions specific to organ donation and transplantation. Additionally, health care risk management concepts as they apply to emerging issues in the organ donation and transplant field are explained. The article also highlights strategies to address particular patient safety issues and concerns. Case studies illustrate risk management applications and lessons learned.     

Integrating disclosure,patient safety and risk management activities

National Quality Forum safe‐practice guidelines encourage hospitals to integrate disclosure, patient safety and risk management activities. Combining collaborative law with a patient safety program in a parallel process makes it possible to achieve this integration. This combination provides for physician‐led guidance in determining whether disclosure is required — and, if so, provides mentor assistance with actual disclosure. It offers proactive error prevention by offering a means to quickly utilize information to make safety changes. Additionally, the combination provides an opportunity to access collaborative law at a time when it is still possible to resolve issues without resort to litigation.     

Patientensicherheit: Welchen Beitrag können Patienten leisten?

Background

Patients and their relatives are the persons who have an overview of the entire process of health care and who can provide safety relevant information within and across all sectors. Yet they are not involved systematically in the process of ensuring patient safety. The aim of this paper is to explore which problematic issues of safety exist from the patient perspective. Furthermore it will be discussed how patients could be involved more in future.

Methods

The data basis of this analysis are focus groups with in total 28 patients. Those were conducted in the period of October to December 2011 by the Department of General Practice and Health Services Research, University Hospital Heidelberg, Germany. All conversations were audio-recorded and transcribed as fulltext. The data analysis was performed referring to the qualitative content analysis of Gläser and Laudel.

Results

On the one hand the focus group participants reported that they were very satisfied with the care they received from the professionals (doctors and nurses). On the other hand they criticised the chaotic management of the clinical care. In the intersectoral care safety relevant issues emerged from the fact that responsibilities were not clear and patients were not sufficiently informed. On the other side the analysis showed that patients and their relatives already contribute significantly to ensure patient safety. In some cases errors have been avoided because patients were watchful, e.g. respectively to their medication.

Conclusion

A stronger involvement of patients and relatives has great potential to ensure patient safety. However, the organizational frameworks have to be more evolved. Related to this, the workload of professionals must be taken into account and organizational structures—intersectoral and interdisciplinary—needs further development.     

Improvements in the safety of patient care can help end the medical malpractice crisis in the United States

The publication of To Err is Human: Building a Safer Health System by the Institute of Medicine (IOM) in 1999 made the general public aware of the large number of patients that suffer preventable medical injuries in hospitals throughout the United States. Improvements in patient safety are needed to reduce this high incidence of medical error and must include the establishment of a culture of safety in every healthcare facility. A culture of safety is characterized by honesty, transparent error communication, and a systems analysis approach to medical error prevention. This type of medical culture can serve as the foundation for sustained improvements in patient safety and will help provide permanent relief from the medical malpractice crisis. Health policymakers should create policies that encourage hospital executives to establish and maintain cultures of safety in their institutions.     

Pediatric anesthesia: A large problem in small people

About 70 percent of all pediatric care is delivered in non‐pediatric hospitals. A variety of factors have prompted community hospitals to initiate or expand existing pediatric surgical services. These include changes in medical economics and the evolving payer system, urban sprawl, patient access demands, and better community availability of pediatric sub‐specialists. Moreover, some community hospitals are providing complex pediatric surgery or are operating on young infants — services that were once exclusively the domain of the tertiary pediatric provider. These recent demographic changes have raised concerns regarding the quality and safety of anesthesia services at these institutions. This article discusses the unique characteristics of the pediatric surgical patient and the clinical risks associated with pediatric anesthesia. The authors offer strategies and recommendations for ensuring patient safety and managing credentialing and privileging issues.     

John E. Wennberg,Pionier der regionalen Versorgungsforschung

Using claims data, Wennberg demonstrated regional health-care variation that was not due to differentials in morbidity nor was it preference-based, but was partly supply-sensitive. The structure, processes, and outcomes of care are imperfectly coupled, and more services are not necessarily associated with better outcomes. Feeding data back to the responsible providers, restraining capacities, and fostering patient autonomy are seen as important in reducing unwarranted variation in health-care service delivery. In Germany, regional analyses of claims data and disease registries confirm the heterogeneity of processes and outcomes. A reduction in regional variation is in the interest of patient safety and likely to improve the effectiveness and efficiency of medical care. More health-care delivery science—both analytic and experimental—is needed.     

Putting safety at the core

To create a deeper culture of safety--an environment in which safety is the first priority of every person in the system--Mercy Health System, St. Louis, has launched a variety of safety and quality initiatives. In September 2005, Mercy began an effort to develop blame-free environments in which the reporting and gathering of data can lead to improvements in patient safety. Mercy's top executives attended Mercy's annual Pathways Leadership Development event in October and November 2005 to discuss the moral and theological imperatives for building a culture of safety. Mercy's leaders addressed six stumbling blocks that have impeded progress toward a culture of safety: production demands and time pressures, absent or inadequate processes, failure to focus on process problems, poor teamwork, inadequate communication, and fear and pride. They have identified five key elements that should enhance patient safety: improved leadership, reporting systems, measurement, best practices, and a supporting structure. For Mercy, the safety initiative is not just about policy change; it's about cultural transformation.     

Putting patient safety in the blueprint

When St. Joseph's Community Hospital of West Bend (Wis.) decided to build a replacement facility, CEO John Reiling proposed a novel approach: Let improving patient safety guide the entire design process. Before ground was broken, St. Joseph's convened a learning lab that attracted some of the nation's leading experts on patient safety. Since then, staff from every sector of the hospital have helped to identify where errors occur, how work flow and processes can change to enhance safety and how a building can be designed to incorporate those improvements. Although St. Joseph's leaders say the goal is simply to provide the best facility for their community, it's likely that their patient-safety-driven design process will become a model for hospitals across the country.     

Data as a catalyst for change: Stories from the frontlines

The landmark 1999 Institute of Medicine report, “To Err Is Human,” challenged us all to reduce the number of preventable medical errors. While vulnerabilities and patient harm continue at unacceptable rates, there are also many success stories. This article presents a series of case studies that illustrate how healthcare organizations have used data—quantitative, qualitative, and comparative—to address vulnerabilities and guide meaningful change to improve patient safety. These examples are drawn from the data‐sharing community of CRICO Strategies, a division of the Risk Management Foundation of the Harvard Medical Institutions, Inc. (CRICO). CRICO's data‐driven strategy uses intelligence from thousands of medical malpractice cases across the country to examine what has gone wrong and why, and to help members and clients manage their risk and provide better care.     

Physician partnerships: The value of clinical effectiveness resource management

Once perceived as a hospital‐only process, risk management is now recognized as an important part of clinical decision‐making and hospital operations. The greatest opportunities exist where risk management programs can be integrated into the development and implementation of guidelines, protocols and order sets that encourage adherence to valid clinical evidence and reduce unwarranted clinical variation in patient care. The limiting factors in this approach are providing the data needed to demonstrate the need for change and engaging administrators and clinicians in the development and implementation of those changes. This article describes a process for the development of hospital‐specific data that can be used to evaluate the cost impact of various decisions about patterns of care — the Clinical Effectiveness Initiative? — in this case used to demonstrate the cost impact of a choice between two medications used to prevent and treat a common disorder, venous thrombosis. It also describes how this data can be used to engage clinicians and administrators in a partnership focused on improving outcomes and patient safety by considering the full complement of factors — clinical, operational and risk management‐related — that contribute to those costs and outcomes. This process is clinical effectiveness resource management.     

Scanning for higher profits. The FDA's plan to require bar codes on commonly used medical products will do more than improve patient safety

Omnipresent bar coding is going to get even more visible. The Food and Drug Administration has pledged to approve later this year a plan requiring bar codes on every dose of medication administered in hospitals. The FDA's initiative is garnering praise for both its capacity to improve patient safety and potential to save money.     

Safety risks in the ambulatory setting

Over the past decade, the focus of safety implementation has been on hospital settings, and most research on patient safety has examined hospital care. Yet, each year, 300 Americans are seen in ambulatory settings for every 1 person admitted to a hospital, and research shows that errors in ambulatory settings can be just as devastating as those in hospitals, and, as in the hospital setting, ambulatory errors or events often trigger legal action. The American Medical Association's report summarizing and compiling the past decade's research identifies 3 general gaps in the current research that impede safety analysis and 6 errors that are most common in ambulatory care that warrant attention. As new models of care emerge with an increased focus on continuity across care settings, there are also nascent opportunities for risk managers to analyze and evaluate ambulatory safety, implement strategies, and develop and test tools that could result in safer patient outcomes.     

Why do good people do bad things?

That was the question Dr. Lucien Leape, patient safety pioneer, posed in the title of a lecture he delivered at a Harvard University risk management conference way back in 1997. As a new healthcare risk manager, I had been asking myself this same question almost every day since my move from nursing to risk management.     

Medizinprodukte und Patientensicherheit aus der Perspektive des Klinikers

In daily routine, clinically orientated physicians are confronted with various, often highly sophisticated medical devices. To ensure safe handling and usage, licensees and operators of those devices have to follow regulations and laws given by the German medical device legislation. For the clinician as an active user of the technology, basic knowledge of these regulations is essential. Quality-based health care focuses on the important issue of patient safety. Medical devices have made their way into virtually every sector of patient care. However, despite usage of these devices bearing substantial risk of adverse events, the problem of safe handling of sophisticated technology plays only a minor part in medical academic studies, medical specialist training, and manda¬tory continuing education of physicians. The option of further education is needed to ensure patient safety and protect operators of medical devices.     

The essential balance: Risks and benefits in food safety and quality

Food composition analysis is concerned with both beneficial and harmful food components in the human diet: nutrients, bioactive non-nutrients, anti-nutrients, toxicants, contaminants and other potentially useful and dangerous elements. The concept of food safety in the past excluded elements of nutrition such as known risk factors for certain chronic diseases and nutrients in the form of fortificants and supplements. Concerns about genetically modified foods, functional foods, high levels of nutrient additives and nutritional supplements are now being taken into consideration in the risk and safety activities of both the Food and Agriculture Organization of the United Nations (FAO) and the World Health Organization (WHO). “Food safety” generally refers to the content of various chemical and microbiological elements in food. More consumer awareness of food safety and quality issues, along with government and industry action, is bringing about a more preventive, food chain approach—sometimes called “from farm to table”—in many countries, so as to improve traditional food safety systems. FAO has adopted this food-chain approach and defines it as recognition that the responsibility for the supply of safe, healthy and nutritious food is shared by all involved, from primary production to final preparation and consumption. Compositional changes (representing either risks or benefits) in food can be introduced at every link. Although developments may be largely beneficial, food composition needs to be monitored to ensure that no harm results to consumers. Finally, collaborative international efforts are needed in order to resolve issues of food-quality and safety across boundaries in a global world trade context. A “holistic food chain approach” would recognize that responsibility for supplying safe and nutritious food lies with all those involved in food production.     

The Cost of Quality: An Academic Health Center's Annual Costs for Its Quality and Patient Safety Infrastructure

Background

In the United States, regulatory bodies, state licensing boards, hospital accreditation organizations, and medical specialty boards have increased their demands for data, public reporting, and improvement. Survey research suggests that as much as $15 billion is spent on reporting quality measures, but those costs, as well as those associated with improvement, have not been sufficiently characterized. A study was conducted to examine, in detail, the costs incurred by one health care organization—an academic health center (AHC) with employed physicians—in responding to quality and safety requirements.

Can your nurses stop a surgeon?

With an "audacious" attitude, leaders at Advocate Health Care have set out to create a culture of safety that permeates every level of the organization. The initiative, inspired by work at Sentara Healthcare, gives all employees the power to stop any action they think might harm a patient or co-worker. More importantly, it creates a work environment in which critical thinking is as routine as breathing.