Treading around level 3: Time for a paradigm shift in patient safety?

Summary

Dr Abdulelah Alhawsawi, Abdominal Organs Transplant and Hepato-biliary Surgeon, and Director General of the Saudi Patient Safety Center, discusses why hospitals are falling short of safe care levels. He believes healthcare continues to be structurally weak when it comes to the safety conditions and suggests that there is an urgent need for a paradigm shift in the way we think about patient safety and how we implement it while providing healthcare. In his essay, Dr Alhawsawi proposes four practical solutions.

Content

Allow me to start this essay with a real personal story: more than a decade ago, while I was doing my Transplant & Hepato-Biliary Surgery fellowship in the USA, I had to have elective orthopaedic surgery. The good news was the hospital where I was about to have the surgery was the number one in the US News Ranking for Orthopedics that year. The bad news was that I was literally ‘terrified’ while I was in the pre-op holding area, just before I was wheeled into the operating room!

How could that be? Me: the surgeon, terrified of having a straightforward orthopaedic procedure in the number one orthopaedic surgery hospital in the US? The answer was yes. It was precisely for this reason – that I am a surgeon who knew what could go wrong in a clinical unit like the OR and that I was terrified of becoming just another casualty of a medical error!

Back in 2016, in their book 'Safer Healthcare', Charles Vincent and Rene Amalberti beautifully articulated the safety levels in hospitals where they classified five levels of care:

• Level 1: The care envisaged by standards.
• Level 2: Compliance with standards / ordinary care with imperfections.
• Level 3: Unreliable care / poor quality, but the patient escapes harm.
• Level 4: Poor care with probable minor harm but overall benefits.
• Level 5: Care where harm undermines any benefit obtained.

As a practicing healthcare professional (a surgeon), I can, unfortunately, say that the majority of clinical units in hospitals are performing around Level 3 (unreliable care / poor quality, but the patient escapes harm) with fluctuations towards Level 4 (poor care with probable minor harm but overall benefits) for below-average performers or Level 2 (compliance with standards / ordinary care with imperfections) for a very few leading medical centres... sometimes!

Patient safety was defined as the absence of harm. I believe it is time to define patient safety using a patient-centric approach where patient safety can be defined as the absence of harm for each patient, by the right person(s), at the right time(s) and the right place(s). Such definition would help us think about a systemic and individual framework to safety, where safety is customised to every patient, all the time, in the backdrop of a safe clinical unit.

Last year marked the 20th anniversary of the landmark paper 'To Err is Human'. Although the past 20 years have seen much progress in the understanding of the healthcare safety which helped bridge the knowledge gap in this significant field, we still have a significant implementation and structural gap, which continues to contribute to the ongoing inherently weak safety conditions for patients.

The main reason for writing this essay is to say that 20 years after To Err is Human, the majority of hospitals are treading around Level 3 (mediocre patient safety conditions to use layman’s terms!). Such a situation is entirely unacceptable for high-reliability industries like aviation, nuclear, and oil and gas. Fifty to sixty years ago, these industries were not as safe as they are today but reached their watershed moments (tipping point) and had to transform their safety practices.

This essay is a call for action to highlight the following:

• Healthcare continues to be structurally weak when it comes to the safety conditions.
• This lack of resilience leads to ongoing medical errors and harm to patients.
• There is an urgent need for us to have a paradigm shift in the way we think about patient safety and how we implement it while providing healthcare.
• As healthcare systems are complex adaptive systems, the only way to do that is to build resilience in the system.

Here are my practical solutions:

1. Adopting co-production principles: co-design, co-delivery and co-assessment. Introducing complementary checklists for both patients and healthcare professionals throughout the patient journey.
2. Safety reconciliation: transition of care or any patient transfer carries potential patient harm – e.g., fall, tubes or IV dislodgement, communication failure with new staff members, such as radiology department technicians, etc. Hence, it is vital that a safety reconciliation is performed by both the patient/families and healthcare professionals (co-production) using checklists.
3. Leveraging implementation science: by introducing safety principles into the day to day clinical practices at the bedside (undergraduate, postgraduate, and board-certified practitioners).
4. Human Factors Engineering (HFE): introducing HFE principles into bedside clinical practice – e.g., effective communication, situational awareness, flat hierarchy and team-based simulated learning – will introduce resilience into the system and help reduce potential harm to patients.