Patient safety as a concern for health systems in Europe
David Schwappach examines the issues that must be addressed if we are to reduce preventable harm. Sometimes simple changes can make a big difference.
Cancer care has seen large successes in terms of increased survival rates and improvements in quality of life. However, despite these achievements, many patients suffer preventable harm from treatment. Cancer care provision has become increasingly complex. Complex systems are characterised by specialisation and interdependency – and that’s what makes them prone to error. Studies of patient safety in cancer care have usually focused on chemotherapy safety and have been conducted in large centers. These studies reveal that errors are more frequent in more complex therapies and that about 1-3% of adult and pediatric patients are affected by chemotherapy errors 1. We know considerably less about safety of other areas of cancer care, small and remote centers and outpatient care.
A recent study conducted in Sweden addressed non-intercepted dosing errors 2. The important feature of this study is that the researchers identified wrong doses that were actually administered to the patient. Researchers recalculated doses according to the guidelines of each institution, using the patient data as documented in the patient record, the paper-based prescription form, or the CPOE system, and compared recalculated doses to administered doses. A non-intercepted prescription dose error was defined as a ≥10% difference between the administered and the recalculated dose. The study reports a rate of prescription dosing errors of 1,7 per 100 prescriptions. The greatest risk for such an error had complex dose calculations, for example, adjustment by renal function and body surface area. Studies on medication errors are important but they do focus on only one aspect of therapy. They do not tell us about the entire risks patients are exposed to during the course of treatment, which may also involve radiotherapy, surgery, etc.
Substantial cumulative risk
A recent study from the US fills this gap and provides alarming data: The investigation by Lipitz-Snyderman et al. studied whether patients were actually harmed and suffered adverse events (AEs) 3. This study assessed the nature and extent of AEs among cancer patients across inpatient and outpatient settings for a one-year period. The used trigger tool included 76 distinct triggers or signals that would lead reviewers to a focused review of the record for the occurrence of AEs, for example, return to the operating room or interventional radiology within 30 days of surgery, or elevated blood glucose levels. During the one year observation, one third of patients had at least one AE and 16% had at least one preventable AE. Thus, the cumulative risk of harmful errors over the course of treatment can be substantial. Still, even these figures probably underestimate the real magnitude since only problems clearly documented could be identified.
How can we improve?
This evidence emphasises that patient safety is a major concern in cancer care. What can be done to generate improvement? Because errors and mistakes are always made by single individuals at the sharp-end, a nurse or a doctor, we tend to respond to errors with individual focused strategies: try harder, be aware, concentrate, be resilient, and finally: get another training (figure 1).
However, these strategies will often be quite ineffective. The reason is that they solely rely on human performance. However, to ensure patient safety, we must improve system reliance and not individual reliance. Interventions to improve patient safety can be people-focused or system-focused 4. Typical person-focused interventions are education and training, rules and policies, warnings and labels. Typical system-focused interventions are forcing functions, equipment redesign, and, very important, culture change. System-focused interventions are stronger. Their effectiveness is high, but requires quite an effort. Person-based strategies are – from a human factors perspective – weak actions (see figure 2). They place heavy cognitive burden on staff working under complex conditions and are thus unreliable. In health care we tend to focus too much on raising awareness of staff and too little on the systems within which work is done.
Weak and strong actions
Strong and effective actions are those targeted at the structural, technological and environmental conditions. A very good example of this is the dramatic problem of wrong application routes with Vinca-Alcaloids. The best way to avoid wrong route applications is to make the application routes incompatible. So vincristine should never be prepared in a syringe for adults or pediatric patients. These products should be manufactured or prepared in a small-volume minibag for intravenous infusion so they cannot be connected to the intrathecal route. This seems a very simple and plausible solution. Still, practice has been reluctant in adopting these rules 5. In many settings, vincristine is still delivered as syringe and focus is put on rather weak actions. We did a survey study among hospital pharmacies in Switzerland this year (Brühwiler / Schwappach, unpublished data). Among hospital pharmacies which prepare vincristine chemotherapies, only few have switched to mini bags and large quantities of the drug are still prepared as syringes. Instead of using such physical constraints, we often rely on human checks, for example double checks. But these are weak actions, due to a number of reasons. We surveyed oncology nurses about their double-checking practices and asked them which factors frequently interfere with performing a good double-check 6. The results are highly alarming: Nearly 60% mentioned noise and poor illumination as hazards at their workplace and nearly 80% responded that interruptions and distractions interfere with a good double check (see figure 3).
Thus, nurses are performing the double check under inadequate environmental conditions. Rather than implementing yet another checking procedure, it would be more effective to change the conditions under which staff works, i.e., poor light, noise, and chronic interruptions.
Safety culture and the price of silence
Finally, a strong and reliable safety culture is an important determinant of safe health care. This includes learning from errors, strong teamwork skills and also speaking out to colleagues and superiors when safety is jeopardised. However, research suggests that nurses and doctors sometimes withhold their voice though they are concerned for safety. In a previous survey study, 70% of oncology nurses and doctors had chosen to remain silent when they had concerns; 50% said nothing to others about potential safety problems they noticed, and 37% remained silent when they had information that might have helped to prevent an incident 7. Important predictors for not speaking up are low levels of psychological safety, for example, not feeling supported by superiors, low hierarchical position and strong authority gradients, and high levels of resignation and frustration among staff. So further work on safety culture in cancer care is required, both, by encouraging staff to speak up and by building organisations that will listen. Combinations of cultural changes and careful design of environment, equipment and processes can bring sustainable improvement and make care safer.
Prof. Dr. David Schwappach is Scientific Director at the Swiss Patient Safety Foundation in Zurich, Switzerland