Chapter 1: A Brief History of Patient Safety

This is the first draft of the beginning of Chapter 1.

• What questions do you have after reading this?
• Is the history of Patient Safety clear enough?
• What about terminology?

Patient Safety is an important enough topic that the World Health Organization (WHO) has a Global Safety Action Plan for the decade 2021 – 2030 (1). In this document, Patient Safety is defined as:

 “A framework of organized activities that creates cultures, processes, procedures, behaviours, technologies and environments in health care that consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make errors less likely and reduce the impact of harm when it does occur.” (p. v.)

When reading about Patient Safety, there are 2 ways of looking at it. The first (called ‘Patient Safety I’) is made up of Patient Safety activities that reduce avoidable harm as outlined in the definition above. The second (you guessed it, ‘Patient Safety II’) is more subtle. It is a focus not just on reducing harm, but in actively promoting a culture of safety.

At first glance, these may not seem to be so different, but as we will see, the more we get into stories and information around patient harm events and how they can be minimized, it will become more apparent that avoidable harm in healthcare settings isn’t limited to individuals making errors. Certainly there are cases of malpractice and negligence, but the vast majority of harm events leave not just patients and families affected, but the healthcare professionals who were involved.

Why Patient Safety?

The Big Picture: Patient Safety World-Wide

There are varying statistics about the prevalence of patient harm not just in Canada, but world-wide. Certainly, if the WHO has a Global Safety Action Plan focussed on eliminating avoidable harm in healthcare, then it is a significant problem.

The WHO’s document cites that 1 in 10 hospitalizations results in a harm event. (Citation needed). For Canada, I have seen stats that say it’s 1 in 17 hospitalizations (citation needed). It’s important to note that, as we’ll see, defining and reporting harm events is not standardized.

In economic terms, the WHO estimates the social cost of avoidable medical harm to be between US $1-2 trillion (with a ’T’) per year. That doesn’t count the impact on patients, their families and the healthcare professionals involved in the harm event(s).

Patient Safety is Personal

That’s why the WHO is looking at Patient Safety, but why should we care?

My personal ‘why’ is because my husband has experienced life-altering harm accessing healthcare. As a lung transplant recipient, he has had access to a medical intervention that is still not available to everyone, even in Canada. There are access issues  in Canada as we have only 5 centres that perform the surgery and required follow-up.

Getting through the process requires candidates to meet both medical and social criteria and if you don’t live near one of the transplant centres there are extra layers of access issues. Post transplant there are any number of issues that can impact your health and longevity and you may find yourself having to travel back to the transplant centre often.

Tony’s transplant, though, wasn’t where his medical harm occurred. We had learned healthcare system navigation skills going through the transplant process, and we have a list of healthcare professionals on the contact list in the patient binder we keep for Tony. These things helped when we did run into avoidable harm events a few years after his transplant.

Tony was getting back to an active life after we moved from ‘up Island’ on Vancouver Island to Victoria so he could be closer to follow-up care for his transplant. He was involved in a Vespa accident that left him with 9 fractured ribs and fractures in his left clavicle and scapula as well as a T12 compression fracture and head/cognitive injuries that are still not fully diagnosed or explained. What was missed, however, was a perforated bowel that developed into hospital-acquired sepsis, landed him on ECMO after he aspirated during emergency surgery and left him with an ileostomy. He was fired by his Victoria-based GP while in hospital in Vancouver because receiving opioid pain medication in the ER put him in violation of the opioid agreement he had been required to sign in order to receive care. So when he was discharged after 6 weeks in hospital, he had no GP. That meant that he had nowhere to get pain medication prescribed and there was no local physician to help coordinate access to rehab or wound care.

We were fortunate that a social worker back in the Victoria ER had advised me to get a lawyer because a motor vehicle accident means having to deal with ICBC. The lawyer we found has his own network of healthcare professionals and he provided some much-needed case management and valuable contacts.

So my ‘why’ in writing about Patient Safety comes because not only are there many, many systemic issues that contributed to Tony’s avoidable harm events (yes, there’s another one…) but patients should not need the help of a lawyer to navigate what happens after the harm event.

Patient Safety in the 1990s

Tony had been through a major health crisis (end-stage lung failure) that saw him get a lung transplant in 2016. There were things along this journey that made us wonder why he seemed often to be under-diagnosed and under-treated but the idea of Patient Safety wasn’t on our radar. We were, honestly, gob-smacked enough that a lung transplant was even an option.

When I looked into the history of transplantation in Canada (I’m a science nerd), I realized why organ transplant had never been mentioned when I did my undergrad (BioSci ’88 – go Gryphons!) It’s because medical developments have been relatively recent. Leaps and bounds in medical treatments haven’t just happened during my lifetime – they’ve happened during my adult lifetime.

Organ transplant wasn’t unheard of, but it certainly wasn’t commonplace, although by 1990 I knew 2 people who had had organ transplants (one kidney, one liver).

And this is the way it is with the Patient Safety movement as well. We may have been hearing the occasional story of ‘bad luck’ when accessing healthcare, but it wasn’t something we talked about.

Patient Safety started to become more of a consideration after World War II when many countries were building healthcare systems (1, p. 2). Canada is no exception to this.

The beginnings of Patient Safety were limited to what I think of as lab safety considerations – fire hazards, equipment maintenance as well as infection control and minimizing patient falls. These are certainly important and are part of current patient safety processes.

As far as healthcare staff is concerned, it was assumed that as long as staff were well-trained they would behave safely and work to minimize errors and complications. That was probably more of an achievable goal in the 1950s, 60s and 70s with the level of medical knowledge and social supports.

Certainly in our experience, Tony’s medical harm events have happened due to the disconnection among his many physicians. Healthcare wasn’t as siloed when there was less of a need for specialists – and even sub-specialists. Today there are so many more details to communicate and we still have no reliable systems to ensure communication happens effectively.

The key point about Patient Safety in this time after World War II is that if/when medical error occurred, the focus was on whether staff were well-trained and/or behaving safely. Solutions, if any were sought, were focussed on training and individual behaviour. Investigations were internal and local, with no thought about similar issues occurring elsewhere in the city, province, country and internationally.

“Essentially, they (error/harm events) were seen as the inevitable cost of doing business in the pressurized, fast-moving environment of modern health care that was saving lives and successfully treating many more diseases. Mistakes happen, it was argued. They were also viewed mainly as local events best dealt with through internal investigation. (1, p2.)”

That focus of patient safety was arguably sufficient for the time. There were relatively few complex and chronically ill patients because they were either restored to full(ish) health or they died. Managing a chronic illness is a relatively new phenomenon and it requires a different set of systems, knowledge and supports – for patients, care partners and healthcare professionals . Medicine has advanced rapidly, but our systems of care have not.

Fast forward to the 1990s, when patient safety began to be seen differently. ‘Adverse outcomes (p. 2) in hospital patients started to be recognized as ‘medical error’. And errors need someone to blame.

In the 1990s, there was a shift in thinking in many industries that when errors happen, it’s not usually the result of one person’s error. Medicine has been slow to adapt to this ’systems thinking’ model, and there is still a strong culture as well as supporting legislation that pits harmed patients against individual physicians. It is outdated and serves neither patients nor healthcare professionals. Take heart that there are initiatives to help move medicine in Canada away from this blame culture and towards a no-fault system of reporting error and we’ll explore these in later chapters.

The airline industry is most-often used as a comparison in healthcare. This industry has embraced that accidents are most often ‘embedded in a complex amalgam of actions and interactions, processes, team relationships, communications, human behaviour, technology, organizational culture, rules and policies, as well as the nature of the operating environment.” (1, p. 2)

Without a doubt, the medical harm events that Tony has experienced in 2/3 of his last hospitalizations happened because of this ‘complex amalgam’. The recourse a harmed patient has is to report one individual physician to a college, take action against an individual physician or report the harm incident to ‘Patient Care’, which is a department that has no real power other than to take the incident to hospital administration. In our experience, the incident is reviewed and generally comes back with ‘all policies followed’.

Patient Safety in the 21st Century

The term ‘Patient Safety’ came into use at the beginning of the 21^st century. (1) (p. 2) and the scale of harm from healthcare began to emerge. With this recognition came the realization that harm events were wide-spread world-wide and not limited to local events. 

Yay!

This is the emergence of the idea of ‘Patient Safety II’. It recognizes proactive measures that emphasize safety are preferred. That is, it is better to set up situations where people can succeed rather than trying to fix ‘failure’ after it has occurred. It shifts the focus from creating internal processes in isolation to including patients and care partners in (hopefully) all aspects of healthcare planning and assessment.  Patient Safety II asks patients and care partners what has made them feel safe, and what would have made them feel safe.

Patient Safety includes patients and care partners. It takes seriously the patient advocacy phrase, ‘Nothing about us without us’. If the goal of Patient Safety is to eliminate harm events and create cultures of safety, then it only makes sense to include the only ones who navigate among the disconnected silos of the system.

Healthcare professionals don’t go to work intending to harm others, just the opposite. We live in a culture that expects us to ‘do more with less’, to hustle, to give 110%. The culture of medicine is still very much focussed on individual achievement. 

The expectations on healthcare professionals are massive. We are functioning beyond what is sustainable. 

And this is where we are. There are Patient Safety initiatives becoming more embedded in our healthcare systems in Canada. Patients and care partners are being included and involved in healthcare planning. It is in its early days, however. We still see avoidable harm incidents viewed as local events, and blamed on individuals within the system. Blaming individuals for what are systemic and policy failures is institutionalized betrayal (find definition) or institutionalized violence (find which one is best). And it keeps patients, care partners and other healthcare professionals from having safe ways to report patient safety incidents.

Patient Safety requires medicine to continue to move away from individual blame so that a culture of safety can be built.