To Err Is Human: Is Patient Safety an Issue in Palliative Care?

In recent years there has been increasing interest and activity within the healthcare system in the area of patient safety. Now that hospice palliative care is part of the mainstream of the health care system we have a responsibility to examine whether patient safety is also an issue for palliative care. The answer of course is an absolute yes.

Safety of patients in Canada 

All health care has the potential to cause harm, and every day thousands of errors occur within the Canadian healthcare system. It is estimated that more than 4,000 people die annually in Canada because of adverse events, which produce harm. We cannot assume that our palliative care patients are immune to such issues, particularly since we work most often within the complexities of the community environment. Most studies on patient safety have occurred within a hospital environment. A Canadian study by Baker in 2004 (1) showed an error rate of 7.5 per 100 hospital admissions, 36% of which were preventable and 21% of which were fatal. In the literature, there is very little discussion of safety within hospice palliative care programs and systems. Dietz et al (2010) report that most of the research on safety in palliative care involve case studies with few large scale studies.

The patient safety movement

In the last decade a number of important documents have become resources for the patient safety movement. In 1999 the Institute of Medicine released a report entitled, “To Err Is Human: Building a Safer Health System” (2). This book examined medical errors in the US, but captured widespread attention among healthcare providers, the general public and among governments throughout North America. Two years later, another report by the Institute of Medicine called “Crossing the Quality Chasm” (3) provided a broader look at problems with quality of care and their potential solutions in US healthcare systems. Chief among its recommendations was that patients should expect and deserve safe care.

In 2002, the National Steering Committee on Patient Safety in Canada released its landmark report, “Building a Safer System: A National Integrated Strategy for Improving Patient Safety in Canadian Healthcare” (4). This led to the establishment of the Canadian Patient Safety Institute. In 2003, the Canadian Patient Safety Dictionary (5) was published by the Royal College of Physicians and Surgeons of Canada and it has become an international resource.

The Canadian Patient Safety Dictionary defines patient safety as “the reduction and mitigation of unsafe acts within the healthcare system, as well as through the use of best practices shown to lead to optimal patient outcomes”. The dictionary also defines an adverse event as, “an injury (temporary or permanent discomfort or disability, physical or psychological) caused by medical management rather than underlying disease”.

Safety in hospice palliative care. Achieving a higher level of safety is also an essential step in improving the overall quality of care that we deliver in hospice palliative care.

Hospice palliative care is definitely a setting for potential error. We deal with patients with serious illnesses, who often have complex pain and symptoms, and psychosocial, spiritual and social needs. The lack of good advance care planning is another barrier to safety. Without planning, goals of care may not be defined and therefore patients and their families are exposed to added suffering. We work in a complex team environment, and lack of accountability to each other and poor communications also provide for possibilities of significant errors.

Patient safety at home

When we look at palliative care provided in the home, a number of authors have pointed out our lack of knowledge about safety in homecare. We know that the key elements of care delivery in institutions often do not apply in homecare. Homecare is often provided by health care professionals and unregulated providers from a variety of organizations and sectors. Together they must coordinate and communicate with each other in an environment that has complexities not seen in an institutional setting. Furthermore, care and safety of patients in homecare settings cannot be addressed without including family, friends and volunteer caregivers along with professional care providers in these considerations. Unlike care in institutions, which is provided by paid employees working under institutional policies and managers, most of the care in the home is provided by the family or caregivers under the very indirect supervision of a healthcare professional. Multiple stakeholders, including the patient, family and volunteer caregivers, may or may not agree with the way to proceed, therefore adding another challenge to safety in the home. Finally, homes are designed for living and not for providing healthcare. It is much easier to modify the physical environment in the hospitals to provide protection for employees and for patients than it is to address this in the homecare environment.

Disclosure and accountability

The tendency in the past has been to blame someone for any error, but it is now recognized that human error is a often a symptom of broader issues within a system. Human performance and therefore errors are influenced by many factors in the system and an individual’s actions must be assessed within the context of the circumstances at the time.

A major issue dealt with recently by regulatory authorities has been the disclosure of error when it has occurred. Achieving the culture of patient safety requires open and honest communication between healthcare providers and their patients and families. The Canadian Patient Safety Institute has released a report called, “The Canadian Disclosure Guidelines” (6). As good communicators, hospice palliative care personnel need to use those skills in disclosing harm, despite our concerns and fears.

Summary

Hospice palliative care must use the variety of methods outlined in the literature to develop new ways to define issues of safety. In defining the problems we also need to look at system changes that will mitigate further problems in safety. The following are key messages in improving safety in hospice palliative care:

1. Safety is everyone’s concern. It is an integral part of quality end-of-life care.

2. Safety involves more than consideration of errors, mortality and serious morbidity; it also involves considering increased suffering.

3. Palliative care environments, like other medical environments are not necessarily safe.

4. Blaming someone for errors does not solve any problems, because safety issues are system issues.



References

1. http://www.cmaj.ca/content/170/11/1678.full

2. http://iom.edu/Reports/1999/To-Err-is-Human-Building-A-Safer-Health-System.aspx

3. http://iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx

4. http://rcpsc.medical.org/publications/building_a_safer_system_e.pdf

5. http://rcpsc.medical.org/publications/PatientSafetyDictionary_e.pdf

6. http://www.patientsafetyinstitute.ca/english/toolsresources/disclosure/pages/default.aspx

7. Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Editors, Committee on Quality of Health Care in America To Err Is Human Building a Safer Health System INSTITUTE OF MEDICINE, NATIONAL ACADEMY PRESS Washington, D.C 1999