We all know that 'to err is human,' but did you know that a recent study by Harvard University showed that more than 50 lakh patients die in India every year due to medical errors triggered by a lack of practical knowledge among the doctors and nurses to handle patients when brought to the hospital?
India is a country where the government spends less than 2% of its GDP on healthcare. Government-funded hospitals are characterised by chronic overcrowding, underfunding, and facilities perpetually stretched to the limit. The government also spends less on lack of access to hospitals, lack of awareness, a low doctor-patient ratio (less than one doctor per 1,000 people), ill-equipped hospitals, an insufficient number of labs and diagnostic facilities, the absence of patient medical records, and so on. The picture of other healthcare workers, including nurses, is equally appalling.
Though most of us are well aware of the ills plaguing the healthcare sector in India, what is often never talked about are the adverse events in ‘patient safety.'
Patient safety is the freedom of a patient from unnecessary harm or potential harm associated with the provision of health care, including hand hygiene, surgery, injection, medication, blood transfusion, infection control, and hospital waste management.
Not only in India, but it is also increasingly getting recognised as an issue of global importance. Hundreds of incidents compromising patient care occur daily in hospitals across the country, but I believe that less than 1% of such potential harm gets reported.
Let us look at a few examples, which are just a few of the incidents from the best hospitals across the country that I’ve worked with or know about and which I'm sure you have read nothing about in any newspapers or on social media.
- A young patient who underwent abdominal surgery returns to the emergency room after five days with abdominal pain. The patient is sent for an X-ray of the abdomen to rule out intestinal obstruction or perforation. X-ray technician sees a scissor in the abdomen – informs emergency doctor – informs surgeon – a patient is counselled for emergency surgery, without counselling for the diagnosis – No X-ray of the abdomen showing the scissor is handed over at the time of discharge.
- An overzealous emergency physician thrombolysis a patient with an acute infarct without waiting for the full MRI scan, which shows a ‘hemorrhagic transformation’ and the patient dies after a massive bleed in the brain – MRI cuts showing the haemorrhage on the initial MRI is not handed over to the relatives.
- Two patients died after ‘colourless’ chlorhexidine was given as a flush instead of normal saline after inserting a central line. The patient dies as a result of incorrect intubation in the oesophagus rather than the trachea.
- A young patient gets his arm amputated as a result of a wrongful ‘direct’ injection in the ‘artery’ instead of a vein without the use of an IV cannula.
- A patient has a urethral rupture after a young resident inflates the bulb of the catheter without inserting the catheter all the way to the 'Y.'
- An elderly patient’s gangrenous hand is amputated under local anaesthesia (instead of general anaesthesia) since the anesthesiologist on call will take some time to come and the surgery resident does not want to miss out on the ‘cutting’.
- A senior doctor’s son, freshly graduated, is allowed to insert a central line. He inserts the guide wire inside the jugular vein. A CVTS surgeon is then called to troubleshoot.
Such cases of compromised patient safety are seldom reported by any hospital unless the patient files a medical negligence case against them. Things are only retrospectively discussed in internal hospital disciplinary or morbidity/mortality committees but never acknowledged, to avoid any dent in the hospital’s reputation and medico-legal litigation.
Hospital staff also voluntarily do not report errors or adverse events (with doctors themselves being reluctant participants), because when things go wrong, news spreads like wildfire and the search to find who is at fault is on. This can all too easily devolve into a witch hunt, with blame-shifting from one person to another, who may then feel threatened if they report such events.
Most of the quality accreditation bodies in the country also have their primary focus on checking only for policies, systems, and documentation in the hospitals, with complete ignorance towards patient safety, and are slowly losing their credibility. In the private sector, attention to the promotion of quality care has been mainly driven by business interests.
Also, external committees incorporated to investigate ‘medical negligence’ cases can usually be manipulated, and are often unfair and biased in their report due to the ‘contacts’ of hospitals and doctors.
Over the last few weeks, I’ve been thinking a lot about focusing on some of the practical solutions rather than the problem and decided to jot them down.
- Differentiating patient safety and quality, which are empirically distinct.
- Once a problem is recognised, it needs to be talked about and openly discussed amongst all the stakeholders – doctors, nurses, technicians, the internal committee, and the staff at all levels in a health facility. The solutions are likely to emerge from sustained communications and dialogues.
- Every facility should develop a plan for training staff, with regular workshops and training on infection control, hand hygiene, and patient safety.
- A culture of reporting, discussion, and learning from mistakes needs to be developed at hospitals. We need a system for reporting errors and lapses in discipline even when no adverse event has occurred.
- Ensuring that patient safety processes are communicated to patients and caregivers before, during and after the medical intervention using different communication means such as videos, mobile apps, etc.
- Introduction of an anonymous reporting system in healthcare facilities to be used by healthcare facility staff, students, residents, patients, and families, or with the use of a ‘Ballot box’.
- Integration of a web-based grievance system and toll-free helpline for patient safety
- Implementation of standard treatment guidelines and treatment flows.
- Patient safety training requirements for graduate curricula for various cadres of health staff, such as doctors, nurses, laboratory technicians, and pharmacists
- Healthcare facility accreditation and strengthening quality assurance mechanisms
- There is a shortage of trained medical personnel in rural areas. The only way to address this is to greatly increase the number of government medical colleges, and increase government financial allocation and spending.
- Creating a safety culture in healthcare facilities and improving communication, patient identification, and handover transfer protocols. Mistakes are common and can be devastating when they occur.
- Extensive data analysis and feedback mechanisms on what happens after accreditation or quality improvement activities in care and safety are implemented.
- In India, the Consumer Protection Act serves as a check/incentive to modern medical practitioners to provide high-quality health care. Unfortunately, even this legal mechanism is not accessible to the poor.
- The ill-advised move of the government of India to allow graduates in Ayurveda to practice surgery must be stopped. Ayurveda can't incorporate surgical techniques while ignoring the other domains of modern medicine. An epidemic of catastrophic complications, disproportionately affecting the poor can be expected if surgical procedures are performed by the poorly trained.
- Also, today’s medicine is increasingly becoming technology driven. New technologies create new methods for producing errors and constant vigilance is required to track these.
In the last 10 to 15 years, many initiatives have been taken by the government of India and hospitals to improve the quality of healthcare services and strengthen patient safety, yet, a lot still needs to be done.
Patient safety issues by and large occur because of bad systems, not bad people.
When the above measures are part of daily practice in an organisation, we can say the seed for a culture of patient safety in an institution is sown.
We must not forget that patient safety is knowledge, it’s intentional, it’s a habit, it’s a way of life, and when it influences a group's behaviour, it becomes a culture.