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  • The cost of patient safety inaction: Why doing more of the same is unsustainable (February 2020)


    Patient Safety Learning
    • Saudi Arabia
    • Reports and articles
    • Pre-existing
    • Original author
    • No
    • Abdulelah M. Alhawsawi
    • Everyone

    Summary

    This article by Abdulelah M. Alhawsawi, from the Saudi Patient Safety Center, first appeared on the G20 Health & Development Partnership news stream. It is copied below verbatim.

    Content

    On January 2020, Patient Safety will be on the G20 agenda (amongst other five health key priorities). One would ask: What is Patient Safety doing on an economic forum like the G20? Another cynic might even add: What is Healthcare doing on the G20?

    The G20 was established in the late 1990s with the objective of its members working together to achieve economic and financial stability. It is comprised of 19 countries and the European Union (EU). The G20 collectively represent more than 85 % of the world’s Gross Domestic Product (GDP), and more than two- thirds of the world’s population.

    Healthcare was only introduced in 2017 during the German presidency.

    Why put patient safety on the G20 agenda?

    Patient harm is estimated to be the 14th leading cause of the global disease burden. This is comparable to medical conditions such as tuberculosis and malaria. In both U.S. and Canada, Patient Safety Adverse Events represent the 3rd leading cause of death, preceded only by cancer and heart disease. In the U.S. alone: 440 thousand patients die annually from healthcare associated infections (HAIS). In Canada: there are more than 28 thousand deaths a year due to Patient Safety Adverse Events. In Low – Middle Income Countries (LMIC), every year 134 million adverse events take place resulting in 2.6 million deaths annually. Having said all that, up to 70 % of harm is . (OECD, 2017)

    In addition to lives lost and harm inflicted, unsafe medical practice results in money loss. Nearly, 15 % of the health expenditure across Organization of Economic Cooperative Development (OECD) countries is attributed to patient safety failures each year (OECD 2017) But if we add the indirect and opportunity cost Economic & Social), the cost of harm could amount to trillions of dollars globally (OECD 2017).

    According to a report by Frost & Sullivan in 2018, Patient Safety Adverse Events cost the US alone 146.1 billion dollars annually.

    When you compare the cost of prevention to the cost of harm, the return on investment (ROI) becomes a “no brainer”. In a study that looked at patient safety ROI for Pressure Injuries, the cost of prevention was € 291.33 million compared to the cost of harm of € 2.59 billion (almost 1,000 times higher). (Demmarre et al 2015)

    Over the past 20 years, numerous efforts were made to improve patient safety in individual G20 countries as well as globally under the World Health Organization leadership. Despite all those efforts, the level of harm to patients persists and 20-40% of health resources are being wasted (WHO). Many healthcare structural causes are responsible for the ongoing harm:

    Healthcare Workforce Factors: In addition to the quality and quantity, the wellbeing and safety of health workforce are foundational to patient safety. A substantial body of research now points to link nurse staffing with patient outcomes. A business case by Needleman (2006) demonstrated cost saving from reduced complications and shorter length of stay associated with higher nurse staffing levels. This relationship is articulated clearly in the Jeddah Declaration on Patient Safety in 2019. Dall (2009) estimated the impact of increased nurse staffing on medical cost, lives saved and national productivity. Their research suggests that adding 133,000 nurses to U.S. hospitals would save 5900 lives per year, increase productivity by $1.3 billion, or about $9900 per year per additional nurse. Decrease in length of stay resulting from this additional nurse staffing would translate into medical savings of $6.1 billion and increased in productivity attributed to decreased length of stay was estimated at $231 million per year. Addressing and ensuring guidelines that are consistent with research findings for nursing staffing in acute settings is a viable key solution to prevent medical errors, improve patient safety and decrease cost of healthcare delivery.

    Healthcare Education Causes: Even though healthcare is provided by multi-disciplinary teams, healthcare education (undergraduate – postgraduate) continues to be conducted in separate settings. This siloed approach results in many of the communication failures / safety failures that are experienced on a regular basis. According to Joint Commission communication failures were the leading root cause of the sentinel events reported to the Joint Commission from 1995 to 2004. Healthcare education requires a serious reevaluation of its current curricula and practices. Furthermore, the lack of patient safety components to the medical and allied health sciences curriculum does a disservice to have safe medical practices imbedded within the day-to-day implementation of the healthcare workforce.

    Patient – Provider Information Asymmetry: The information and communication gap between the healthcare providers and their patients has caused ongoing harm. With the information abundance, patients turned to the internet as a source of guidance, regardless of its accuracy, which is minimally provided by Healthcare teams. Healthcare providers need to be the trusted guidance for information and the empowering force for patients to make informed decisions. Unempowered patients may result in lack of transparence and noncompliance to the care plans that contribute patient harm. Major movement for patient empowerment and community engagement is warranted. In addition, engaging patients can reduce the burden of harm by about 15%, saving billions of dollars each year. (WHO)

    Poor Safety Culture: The Hospital Survey on patient safety culture has been implemented in many countries to gain insight on the employees’ perception of the hospital patient safety culture. It has been consistently found that employees perceive hospital cultures lack transparency and results in punitive consequences when adverse events are reported. ‘Shame and Blame’ culture is one of the major barriers to improving safety. It is imperative that healthcare systems adopt strategies enabling Just Culture.

    Lack of consideration of Human Factors: In the healthcare sector, and since the Institute of Medicine (IOM) report “To Err is Human”, have come a long way in improving our services with elimination of potential harm in mind. However, healthcare can learn much more from other industries that have improved safety through use of HFE in redesigning work process and flow to ensure they are error-proof. HFE is an important discipline that can embed resilience to healthcare systems and could, potentially, transform patient safety.

    Lack of sufficient sharing and learning: The different sectors within the healthcare industry have created silos based on profession, departments, type of organization and many more subcultures and entities within a facility and at the national levels. This results in fragmented systems working in isolation, creating piece meal solutions and multi-levels of communication gaps, let alone the opportunity to share and learn in a manner that prevents harm from being repeated. Learning (from within healthcare), through Reporting & Learning Systems, and (from other industries), e.g. aviation, nuclear, oil & gas, is essential to healthcare safety innovation and transformation. Furthermore, population ageing has significant implications for patient safety as older adults are at higher risk for medical errors and the rate of adverse events due to increases in frailty, comorbidities, and incidences of chronic conditions, falls, and dementia makes providing health care more complex and increases costs. Individuals 65 years and older are at a two-fold risk for developing adverse events when compared with individuals between the ages of 16 and 44 years. (Brennan TA, Leape LL, Laird N, et al.) Nations across the G20 will face this challenge, which necessities innovate safety interventions and new approaches in health care to design a safer health care system.

    When it comes to patient safety, doing more of the same will result in: 

    • More lives will be lost 
    • More preventable harm will take place like Healthcare Associated Infections, medication errors, Anti-microbial Resistance (AMR) …etc. 
    • More money will be wasted (not to mention indirect cost and opportunity cost).

    When a patient is harmed, the COUNTRY LOSES TWICE: The individual will be lost as a revenue generating source for society+ the individual will become a burden on the healthcare system because he or she will require more treatment. 

    Unless we do something different about patient safety, we would risk the sustainability of healthcare systems and the overall economies. 

    Our G20 proposal for patient safety

    Establishing a G20 Patient Safety Network (Group) that will combine two types of expertise: 

    • Safety experts from healthcare and other leading industries (like Aviation, Nuclear, Oil & Gas, other)
    • Economy and Financial Experts

    This will function as a platform to prioritize and come up with innovative patient safety solutions to solve Global Challenges while highlighting the return on investment (ROI) aspects.

    This multidisciplinary group of experts can work with each state that adopts the addressed Global Challenge to ensure correct implementation of proposed solution.

    Benefit 

    Investment in Patient Safety – – > sustainability of healthcare systems – – > and overall economies.

    In conclusion, patient safety is a global priority that goes beyond healthcare. It is a challenge that requires the collective wisdom of the G20 and the overall global community. It is not just an issue for health ministers, but it is an important issue that requires the attention of finance ministers and heads of states. The economic cost of failing patient safety could be risking the sustainability of healthcare systems and the overall global economies.

    WE NEED TO ACT NOW!

    2 reactions so far

    8 Comments

    Recommended Comments

    Dear PSL

    Patient Safety Inaction:  The author provides a brilliant but harrowing global synopses to a global forum. But: there is a solution borrowed from Industrial H&S.

    Example: Patient Ward Safety Solution Post Op

    Over a 10-year period, missed ward-guidelines due to human error (HE) responsible for 33,000 post-heart attack deaths,(1) 450 opioid deaths at GWMH,(2) 60,000 life sign (3) with 70% of adverse-event deaths in the UK ward related (4).

    Our NHS has no HE recovery protocols (5) and a massive LATENT SYSTEM ERROR seemingly repeated globally across the healthcare sector. Within the Industrial H&S Sector this latent error attracts the authorities interest.

    Patient ward safety solution: Software driven eQMS will detect HE, apply “compelling klaxon feedback” and reduce HE 10,000 fold (5) without paper checklists. Software stores the Controlled-Copy Care Plan, its associated ward medical interventions and patient MR.

    Ward examples: Prior to any medical intervention on the ward, clinician and patient tag ID to access the patient's records. Whether it is 6 life-sign interventions, 13 post heart-attack, or stepped opioid pain relief, when requested on screen the patient tags their wrist identity confirming the discharged compliance updating their care plan and MR automatically. At closure, any intervention not tagged by the patient compellingly alarmed and corrected. Patient safety is maintained, the clinician and NHS protected from corporate manslaughter fine or jail.

    Conclusion: Software driven tagged eQMS with compelling HE recovery protocols is also a tried and trusted Bank safety system used 30-million times a day in the UK. This professionally endorsed system can therefore be understood and adapted by NHS staff who provide the service across different Departments saving thousands of patient lives, litigation and bed-days with the speed and simplicity of a tagged patient wristband.

    References

    [1] http://eprints.whiterose.ac.uk/102026/1/Excess%20mortality%20and%20guideline-indicated%20care%20following%20non%20ST-elevation %20myocardial%20infarction.pdf 

    (2016.) : C.P.Gale. page 2. missed guidelines. 33,509 deaths in 10-yrs. 

    [2] https://www.theguardian.com/society/2018/jun/20/gosport-war-memorial-hospital-opioid-drugs-policy-inquiry

    [3] https://www.pharmaceutical-journal.com/news-and-analysis/news/national-early-warningscore-aims-to-standardise-patient-monitoring/11104684.article?firstPass=false 

    (2012). 6,000 life sign deaths yearly.

    [4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1281594 Neale, Woloshynowych, Vincent. Exploring the causes of adverse events in NHS hospital practice. J R Soc Med. 2001 Jul;94(7):322-30. 

    [5] The Blame Machine. R B Whittingham. ISBN 0-7506-5510-0.  Industrial H&S: Understand how to improve safety by focusing on systems, not people. (2004)  https://books.google.co.uk/  then type “5.3.3.2. recovery factors” (page 78). Compelling feedback Pr < 0.0001 or HE reduced by a factor better than 10 to the power 4 or 10,000..

    I would be interested to hear hub members feedback on this.

    Derek Malyon

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    Hi Derek 

    I work in the NHS as a nurse.  I am not in any way IT or digital savvy, but I would like to comment.

    I visited a US hospital on an exchange last year.  I saw the benefits of using e wristbands in many situations; drug administration, medical notes, treatment requests and communication between teams even down to what type of surgery and the equipment that is needed for that surgery. 

    I could see that it solved numerous problems it could solve.

    It boils down to money, finding a wristband 'brand' that will fit all of the NHS requirements and needs and most of all the NHS needs to use just the ONE type.  What ever digital system we use it needs to be the same one.  Standardisation is the key, but with multiple budget holders and differing needs among providers we may end up with different types that do not have the same safety standards.

    This is a great question for anyone working in NHSX

     

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    Dear Claire Cox.

    Thank you so much for replying to my post.

    I believe you are referring to NHS Scan4safety launched ~ 2016 and trialled at half a dozen hospitals as we speak. It is brilliant our NHS is picking up on old digital technology like this from decades ago and leading the way globally in the health sector. Human factors, eQMS and Industrial H&S blitzed their subjects decades ago. The NHS could do well to stop reinventing the wheel and apply the system described eliminating human error on the wards saving 1000's of lives and £-Billions annually. The banking sector eQMS did this decades ago and mandatory to remain in business.

     

    It is nigh impossible to get past the front desk of CQC,Sir Robert Francis NHS Imp Scan4safety NHSx NIA AHSN Operation Magenta Kent & Essex Police and board member Professor Carl Macrae. All approached all completely lost. NHS, you have no human error recovery protocols and the global healthcare's Achilles heel.

     

    Kind Regards

    Derek Malyon.

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    On 06/03/2020 at 18:18, Patient Safety Learning said:

    @Gary Saunders Any thoughts?

    Scan4Safety is an initiative led by DHSC - @Richard Price I believe the University Hospitals Plymouth NHS Trust is using this?

    Hi Richard (Scan for Safety) Gary (NHSx)

    I am new to PSL and admit to being overawed by the options. 

    Would you have read "The cost of patient safety inaction: Why doing more of the same is ..." by abdulelah M. Alhawsawi and my post: Patient ward safety solution: Software driven patient tagged eQMS will detect HE apply “compelling klaxon feedback” and reduce HE 10,000 fold (5) without paper checklists. Are you able to comment?

    Kind Regards

    Derek.

     

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    Hi there, I lead the Scan4Safety programme at University Hospitals Plymouth NHS Trust (UHP). UHP was selected as one of 6 demonstrator sites in 2016 by the Department of Health and Social Care (DHSC) to pilot common ways of working using globally recognised standards (GS1 & PEPPOL) within the NHS. 

    UHP and the other pilot sites (Leeds, Derby, North Tees, Salisbury & Cornwall) adopted core GS1 standards that uniquely identify every Patient, Product (Class III implants) and Place within 3 primary use cases (Inventory Management, Product Recall & Purchase 2 Pay) mandated by the DHSC.  The benefits gained have been significant which have concentrated on patient safety and operational efficiency, there has been over £1m cash releasing savings to date at UHP. 

    One key driver was the accuracy and time it took to recall products and how Trusts could identify patients & products quicker using electronic systems instead of paper records.  At the beginning of the programme there was a parallel cited between Retail and how they can recall products quickly from shelves and Healthcare, where it can take many weeks/months and not all patients may have been identified eg. PIP breast implants & metal on metal hip replacements.  The recall time for all pilot Trusts was reduced to only a few hours.  It now takes seconds to identify individual patients and the exact product and location within a computer system, reducing the amount of precious clinical time spent searching through individual patient notes. 

    There has also been a focus on positive patient identification using the NHS ISB1077 standard and the adoption of a GS1 2D data matrix barcode for all In-Patient wristbands.  These barcodes are then scanned when using digital systems to ensure the correct electronic patient record is used, this does not replace verbal identity checks.  At UHP new born patients are now given printed wristbands instead of handwritten ones where verbal identification is potentially difficult.

    UHP now has an overarching trust-wide GS1 policy (http://www.plymouthhospitals.nhs.uk/download.cfm?doc=docm93jijm4n7633.pdf&ver=10685) and is continuing to pursue further use cases; RFID tracking for portable medical equipment and surgical instrument trays, a medicines tracking app using the GS1 EPCIS standard and a never event module to alert when wrong sided implants are selected within theatres.  The programme is now looking at what else could be supported in the future, dependant on additional funding being secured.

    From the original DHSC programme, there was a national website developed (https://www.scan4safety.nhs.uk/).  GS1 UK worked closely with the national programme and pilot sites and have a lot of information on their website (https://www.gs1uk.org/our-industries/healthcare) and dedicated healthcare web pages (https://healthcare.gs1uk.org/).  There are fast follower Trusts taking forward GS1 standards as well, case studies for some of these Trusts and the demonstrator sites can be found on the GS1 UK website.

    The DHSC central team was disbanded in April 2018 and the programme was agreed to be transitioned to the new NHSx team.  GS1 regional adoption groups meet regularly to continue to take this agenda forward.  I chair the southern group, which has good attendance and collaboration between Trusts.  It has been challenging for other Trusts without a central NHS team focused on driving adoption forward.  It is hoped that NHSx will begin to release information on how they will support the Scan4Safety programme nationally to achieve the same benefits for the rest of the NHS.

    If anyone wants to know more about how UHP is taking the Scan4Safety initiative forward, please do not hesitate to get in contact with me directly (richardprice1@nhs.net).

    KR

    Richard

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    Edited by Richard Price
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    Richard

    We do not need paragraphs of Scan4Safety downloads You are doing great work guys.

    Answer the proposed SOLUTION to the following:

    NHS killing 100,000 patients in a 10-year period due to missed NICE/WHO ward guidelines. FACT.

    I provided you with a global solution to a global problem.

    Please engage, take the time to understand research and learn. Contact Profs Macrae, C. P. Gale and Abdulelah M. Alhawsawi.

    I am not here to attack you, missed ward guidelines Kill patients. The global healthcare sector has no human error recovery factors on these wards. That is a management  LATENT SYSTEM ERROR the Police take a very dim view of across industry.

    Derek.

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