Year: 2005
Type: article
Abstract: Canadian Patient Safety Institutea senior healthcare executive, I experienced several incidents in which patients were adversely affected, though no one had intended to harm or compromise anyone.While these were all difficult and painful, I remember one in particular, in which a patient died on a procedure table due to medication overdose.I remember the emotions of the parents and everyone involved as if it were yesterday.All knew this was an unnecessary loss.Anyone who has worked in a hospital any length of time has seen patients grievously affected by an adverse event.No one goes to work in healthcare anywhere wanting to make an error.Canada's health professionals and our many other staff are committed to providing care to anyone in need.But occasionally something does go wrong.We know that somewhere between 9,000 and 24,000 people die annually (Baker et al. 2004) from an adverse event in hospitals.And how many more have been adversely affected in home care, long-term care or community care?The research mostly has yet to be done in those areas.So who is responsible?And who is going to "fix" the nowwell-known problem documented by Baker et al.? We are not going to fix the problems by focusing on individual(s) caregivers; instead we need to focus on the system.I have travelled across the country and heard from professional caregivers -doctors, nurses, pharmacists and many others -and they yearn to give safer care.That aim resonates with Canadian CEOs who recently attended a session with Dr. Donald Berwick, CEO of the U.S. Institute for Healthcare Improvement.To get at the issue, boards and CEOs of hospitals must make patient safety a priority, and a few have begun this journey.So too must community and other healthcare organizations.Researchers must help us better understand the problems and the underlying causes -be they processes, human factors, design of equipment or supplies, systems, etc.We must learn from the work of the airline industry and other high-risk ventures that make safety a priority.We must learn and apply all of this to our complex system of healthcare.It will not be easy and it will take time.I believe that part of what has created compromises in patient safety is the fact that we are asking our staff to master new technologies, processes, drugs, equipment, knowledge, etc. at an alarming rate, and asking them to be increasingly efficient and effective.The culture of our organizations must change.Being able to report adverse events without blame or retribution, to participate in addressing the causes and to disseminate the
Source: Healthcare Quarterly
Author: Hilary Short
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2142428528