Ehi Iden

Let’s start with a story I was once told… There once was a very successful farmer who hired many people to work on his farm; at a glance, you could see countless heads of men and women tilling the ground. He grew very rich. The wealthier he became the more people he hired. His farmland kept increasing every year until it got to the boundary of a river. Although there were many workers, the farmer knew everyone by name and was able to account for them on a daily basis. However, over time, he noticed some workers who came to work could not be accounted for – they went missing. The farmer became worried. He realised those workers who went missing were last seen tilling the ground close to the boundary of the riverbank. He closely observed the riverbank and on one fateful day he saw a wild sea creature come out of the water towards a worker who had his back to the river. Being a good hunter, the farmer positioned himself and watched closely. When the sea creature got close to the worker the farmer fired his gun and killed the creature before it could harm the worker. The workers saw this and realised this creature has been responsible for the sudden disappearance of their colleagues over the past couple of weeks. The farmer realised that many dangerous creatures lived inside the river behind his farm and that this had left his workers unknowingly exposed to a very high risk. The farmer got rid of the sea creature, moved his workers away from the riverbank and reassured everyone of his continuous responsibility towards their safety. After, the farmer wrote down what he saw; he titled it ’The Minutes of the Minute’. Workplace health and safety When I reflect on this story, I realise we all have ‘The Minutes of the Minute’ in workplace health and safety, in patient safety and in quality improvement, but they are usually not documented for us to review and learn from. Accident and harm happen on a daily basis but we hardly ever have clear records of what led to the harm. We have become so used to such harm that it is often overlooked and seen as a part of the system. Every near-miss is a potential lost life if not reviewed, checked and controlled, but most of the time we see them and overlook them. No one ever takes the minutes of the minute; we never know the details of what led to the near miss. When it happens next, it’s no longer a near-miss but a clear harm to patients. Until such a time where everything that happens every minute within healthcare systems becomes our collective concern, patient safety will only be an illusion that we will all continue to struggle to fully understand. We need the right kind of leadership. We need hospital boards that are not made up of armchair rocking and profit-minded investors, but that are patient-centric, compassionate and empathetic modern-day thinking people. We can only profit when we get safety right: the lives we save, the families we keep together, the smiles we put back on the faces of patients and patients’ relatives. These are unquantifiable streams of profit that come with a sense of fulfillment. Going back to the story, the farmer knew everyone who worked for him despite the huge population of workers. What does this tell us? Whatever is important to you, you create time for it. You cannot manage what you do not understand. Every healthcare worker differs and may need to be managed in different ways. The farmer was observant enough to notice some of his workers were missing, even noticing where last they worked before they went missing – this is accountability. We may not notice some sudden obvious changes in our colleagues or employees behaviour – for example, they may become toxic within the patient care team, and it will only take time before such toxicity in behaviour leads to a patient being harmed. Every near-miss, adverse event and incident should be followed by a post-mortem: investigating what happened, why it happened and adjusting the systems towards mitigation. This is learning from incidence. Patient safety as a goal If patient safety is indeed our goal, then every member of the healthcare team needs to look out for each other and offer mutual support. Over working healthcare professionals is the new risk in patient safety but looking out for each other and mutual support is an effective antidote. We need to encourage reporting with an honest and clear motive – not because you want someone victimised or blamed but because you want to create a learning curve out of the situation for system improvement. This culture of honest reporting without blame creates a healthy and safe system for both the patients and caregivers alike. If healthcare leadership is all about sitting in boardrooms you are cut off from reality and are ignorant of what happens at the bedsides. The farmer in the story did not find out what was responsible for his workers disappearance by sitting in a big rocking chair dishing out orders, he went to the centre of the risk. Good leaders lead from the front. You can only see so much when you stand back; the hidden things become visible only when you move closer. Seeking outside help may not fix your healthcare systems; if you look inward and closer at the risks, you will find solutions. This was what the farmer did and today we have “The Minutes of the Minute” as coined from his story. We must remember, what is not documented is easy to forget. When you take down the ‘Minutes of the Minute’, you are documenting the highlights of the key issues that happened within the minute of the act that led to patients’ harm or the accident. We will always need this to learn from, to create an invaluable learning experience towards building safe systems that provide for patient safety.

In March 2017 in Nigeria, we had two very shocking incidents which left everyone saddened and disturbed. The first case was Emmanuel Ogah, a medical doctor, who stabbed his 62-year-old mother to death in Lagos. Then, whilst we were all trying to come to terms with that incident, on the 19 March 2017 Allwell Orji, another medical doctor, asked his driver to stop in the middle of the popular ‘The Third Mainland Bridge’, got out of his car and jumped into the lagoon where he drowned before help could come. The loss of these two medical professionals happened within a space of one week. As an occupational health consultant and a patient safety advocate, this got me thinking about how it further increases the risk exposure to the patients. These were both doctors who were trained to care for patients. Could they have been overworked? Were there issues surrounding their personal lives, their family lives and other very personal issues that were responsible for these acts? Nigerians were not known to commit suicide, but we cannot boast that any more, we are fast losing our resilience and coping capabilities. The World Health Organization (WHO) 2016 report revealed that Nigeria had the highest suicide rate among African countries, ranking sixth globally. This is concerning and needs urgent actions to stem the tide. Let’s look at healthcare professionals being overworked as a key example. According to the Premium Times Report published in November 2015, the population of Nigeria was 173 million people in 2013. Going by that report, Nigeria needed a minimum of 237,000 medical doctors to care for the Nigerian population, in line with the WHO ratio of 1 doctor to 600 people within a population group. But from all reports available at that time, there was only 35,000 doctors actively working as medical doctors in Nigeria. According to this ratio there is no way that doctors will not be overworked. Using these figure, this meant 1 doctor to 4,960 people. Although, the Nigeria Medical College train more than this number of doctors, many move into other professions. Using these figures, we might conclude that workload could be a strong contributing factor to suicide or death amongst doctors and other healthcare workers in Nigeria. So the question is, how does this impact on patient safety? It is sad that mental health was not included amongst the list of occupational health diseases or illness in the International Labour Organisation list of occupational diseases until much later when the toll of mental health issues became so obvious. Psychosocial hazard has become a huge issue within the healthcare work environment leading to burnout, fatigue, exhaustion, stress, tiredness and sleep deprivation amongst healthcare workers, and these outcomes impact negatively on the safety and quality of care when treating patients. The need to keep healthcare workers safe and look after their mental health is something that needs our collective actions and commitment. It takes a safe healthcare worker to deliver safe healthcare to patients. We should be looking at the workload – the duration and frequency of duty shifts within the healthcare sector – which has long changed over the years, making healthcare professionals work longer hours per shift, dealing with a workload that is beyond their coping capacity. We all agree that in healthcare we deal with lives and any mistake within healthcare delivery is always a costly one which innocent people pay for with their precious lives. Work overload is a critical issue surrounding daily patient harm in the hospital. It hurts the patient as much as it hurts the healthcare workers. This workload, if allowed to persist for too long, alters the mental wellbeing of the healthcare worker leading to avoidable mistakes, irrational behaviour, lack of co-ordination and a disrespect to the right and dignity of patients. This is never in anyone’s best interest. There are many doctors, nurses and other healthcare staff who love their jobs and keep giving all they have, giving mutual support to colleagues when they perceive them to be overwhelmed with work, which sometimes leads to collective burnout within a team. which leads to patient harm. Such healthcare staff are seen as trusted by everyone and tagged 'MR FIX IT' because of their willingness and availability to always show up to help or assist. They become a victim of patients' and colleagues' continuous demands; they never say NO but instead are always there to help, but over time they become emotionally overdrawn and this can lead to patient harm. The mental health of doctors and other healthcare professionals should be taken seriously owing to new and emerging conditions and disruptive behaviour noticeable amongst healthcare workers. The two doctors cited at the beginning of this write-up were managing patients entrusted to their care. Any doctor that has suicidal thoughts is a risk within the healthcare environment, no matter the department or unit he or she works in. I really think this is where we must look more closely at human resources, management and leadership in the healthcare environment. These are not roles that should be assigned to a newcomer, but a role carried out by very experienced professionals with a strong analytical background in human psychology and a big heart for employees’ wellbeing. We cannot rule out the fact that the two doctors cited earlier never displayed violent or suicidal behaviours that would have attracted the attention of co-workers, or even the human resources managers who would have been expected to have a meeting with such an employee with obvious suggestive indicators. We need to start engaging our colleagues, we need to start setting up Employees Assistance Programs (EAP) and we need to start looking beyond work – taking an interest and asking what happens in the home of our employees and colleagues. Are there issues? Are there smart ways we can help out? This should be our thinking. It will save both the patient entrusted into the care of the healthcare workers and the healthcare workers themselves and maintain a good reputation for the healthcare facilities. We must understand that healthcare workers are human beings just like us all; they are not super men and women, and they are fallible like every one of us. We need to start re-humanising our workplaces. Let’s start reviewing the workloads, timelines and deadlines, let’s once again treat healthcare professionals the way we would want them to treat our patients. Let’s bring dignity of labour back to healthcare, let’s again work like one big family where we all continuously watch each other’s backs, let’s rebuild the lost confidence while having the patient at the centre of these thoughts. Losing more doctors from healthcare, seeing others behind bars due to homicide, and seeing others incapacitated and feeling invalid when we know the work pressure and work environment contributed to these conditions and states is no good to any of us. We can change it. It takes a HEALTHY doctor to offer a SAFE healthcare.

In the early days of my career, I worked with clinical teams while managing a hospital and later a network of hospitals. I must say, the experience I gathered in these different roles shaped me into what I am today. I can fit into healthcare conversations easily because of these early relationships and interactions with clinical experts. When I look back to my experience as a hospital administrator, a particular incident keeps coming back to mind; I sometimes link this to my later involvement in patient safety but most times I feel it is my conscience speaking to me. There was a patient we were trying to give a surgical intervention to; although he was already in a bad condition, he stood a chance to survive yet he died. We had an antenatal case we had managed from conception and the lady had opted for an elective caesarean section (CS). When she was term, we brought her in and prepared her for the theatre. At the time set of the surgery, our anaesthetist was not available; he was assisting another surgery in another facility, but he gave us a name of his anaesthetist colleague we could use for this patient. We brought this new anaesthetist in to assist in the patient’s CS. While we stretchered in the lady for her elective CS, a severe emergency case was rushed in needing an urgent surgical intervention. This case obviously had to override the elective CS in order of triage. We returned the lady to her ward while we rushed to the emergency case. The medical team that was going to operate on the CS patient was now needed for this new case. About 20 minutes into the surgery, our lead surgeon came out of the theatre with an upset look on his face. I sensed something was wrong and I immediately led him into my office which was near to the theatre and locked the door. I asked him what happened? He told me that there had been an anaesthesia accident. The new anaesthetist we brought in to assist with the surgery had not understood our anaesthetic machine as he had never used it before. He had used the machine incorrectly and had given the patient an overdose of gas and the patient’s heart packed up. The lead surgeon was very upset. I was thinking, this could have been my Dad, my Mum or any of my family members; it was a totally life-changing experience for me. The relatives of the patient were notified that the patient had died; there was wailing and shouting in the hospital. I locked myself inside my office and cried because I knew this patient should not have died from an error of one man. I imagined the pain we had caused the family; the grief and the vacuum we created by our error. It was all too much horror for my fragile heart to deal with at that time. But the greatest mistake we made was that the error was never discussed among the team for us all to learn from and we were also not honest enough to own up to the patient’s relatives. This incident led me into researching and reading materials on medical safety and this was how I got into patient safety advocacy. But when I look back at the incident today, was it the anaesthetist’s fault? No not at all; it was the fault of the system. The anaesthetist should not have been allowed access to that machine in the first place as he had not been trained to use that machine. This was where we should have trapped the risk before it got to the patient. In safety, when you change or replace a machine or a piece of equipment your policy must be reviewed to capture the new equipment and users must be trained on the new machine in its specifications and peculiarities. This is what happens in aviation. A pilot cannot fly an aircraft which he has not been simulated to fly and this is one of the reasons why aviation is still one of the safest sectors in the world today.[1] Having established that it was a system error, we should have also been professional and honest enough to let the relatives of the patient know what had actually happened. When we are honest it shows clear transparency, but when we try to sweep things under the carpet it is mostly misunderstood that our actions could have been deliberate. As I am writing this article, I am sure the relatives of the patient, many years down the line, still don’t know what actually happened. Following the Communication and Optimal Resolution (CANDOR) processes,[2] we should have made an early and honest disclosure of the adverse event known to the patient’s relatives, offered them an apology, refunded their payment and let them know how much this mattered to us and what we were going to do to improve our system. Our actions totally contravened all required amicable and fair resolution for the patient’s family. Owing to the fact that every man is fallible – this is why we are mere mortals in the first place – there may be errors but losing the opportunity to learn from those errors is deliberately creating new levels of errors. We never discussed what happened to our patient. I was the only one who got to know about this incident outside the clinical team who were in the theatre when this happened. The Medical Director may not have even known, so the case was never discussed and we could never all learn from it. When I think of this, I feel we need more openness and information sharing in healthcare, allow teams to discuss and share experiences, give room for reporting without blame, design a system that encourages patient safety conversation and liberalise communication processes. Each time this incident crosses my mind, I think of the lady who we had originally booked for elective CS. This clinical team was put together for her CS before the sudden emergency that came to take her place. She never knew what happened. The evening of that same day her CS was done and she had her baby boy who should be a grown man now. This brings to mind the bible verse Isaiah 43.4 “…I will give people in exchange for you, nations in exchange for your life”. Could this have been what happened? No, the system is what killed the patient and I think we should all own up to this. References Kai-Jorg S. Pilot training: What can surgeons learn from it? Arab Journal of Urology 2014;1: 32-35. Agency for Healthcare Research and Quality (AHRQ). Communication and Optimal Resolution (CANDOR).