PREVENTABLE HARM IN HEALTHCARE

INTRODUCTION
“Primum non nocere”, the Latin phrase that means “First, do no harm” is part of the Hippocratic Oath and is a basis for ethics taught in medical school. Preventing harm, in the context of healthcare delivery, is of great importance to patient safety, overall quality and reducing the cost of care. While a goal of zero harm is desirable, this is not always possible given that healthcare provision is extremely complex. The focus of this article is on managing the risk of preventable harm. It is therefore important to develop a clear understanding of the nature of preventable harm. Once preventable harm is clearly defined, one can deal with this problem more efficiently.

DEFINITION OF PREVENTABLE HARM
There is no academic consensus of what constitutes preventable harm and no single definition is supported by the medical community as a whole. Most definitions (there are over 100) include that the harm should be attributable to an identifiable and modifiable cause and that the harm is preventable in future. Since a complete identification of identifiable harm is not the subject of this article, we will be using the definition of the Institute for Healthcare Improvement: ¹ “Unintended physical injury resulting from or contributed to by medical care (including the absence of medical treatment) that requires additional monitoring or hospitalization or results in death.”

EXTENT OF THE PROBLEM
The World Health Organization (WHO) estimates² that in high income countries as many as 10% of patients are harmed while receiving hospital care and, further, that 50% of these cases are preventable. In low/middle income countries the percentage of patients suffering harm is slightly lower at 8% but 83% of these incidents were preventable and around 8% fatal. The WHO further estimates that preventable harm to patients in care is one of the 10 leading causes of death worldwide. Some scholars estimate that 10 – 15% of healthcare costs in the United States can be attributed to the direct consequences of healthcare related patient harm.³ Already in 2012, preventable harm was estimated to cost the United States $19,5 Billion and malpractice insurance costed an average of $123 for every patient the hospital treats. Some experts calculate that in 2019 the results could be as much as 10 times more. ⁴ Reducing patient harm has been identified as one of the main areas needed to improve both outcomes and costs of healthcare. The US Department of Health and Human Services is forming partnerships with patient initiatives and has specifically targeted a reduction in preventable harm by 40% as one of its two key goals Partnership for Patients: Better Care, Lower Costs. ⁵ It is thus clear that addressing the issue of patient harm is not only of great importance to improving the standard and quality of healthcare, but also to reducing the overall costs and promoting access to such healthcare.

POSSIBLE FACTORS CAUSING PREVENTABLE HARM
It should be noted that the total elimination of preventable harm is not a realistic goal – healthcare providers are human beings and as such eligible to make mistakes. ⁶ Nevertheless, and as can be seen from the above statistics, the need to effectively manage and reduce preventable harm is acute. Various reports and papers have been written on the matter and most agree on the following main causes for preventable harm:
1. hospital acquired infections
2. surgical errors
3. medication errors
4. misdiagnosis

Most of these causes come about through communication errors ( between physicians, nurses, patients and other healthcare providers), insufficient information (may be lacking when care needs to be co-ordinated, prescriptions decided or results interpreted), patient related issues (insufficient patient education, inadequate patient assessment), staff problems ( staffing may be inadequate, staff may be overworked or not effectively trained) and technical issues (devices may fail, may not be operated properly or not maintained properly). Preventable harm is a result of a multitude of factors and often organisations attempt to blame individuals or a particular set of circumstances, failing to understand the complexity of the problem. This leads to the question of what hospitals can do to address the issue in complex, fast paced and sometimes chaotic circumstances. Healthcare providers may look at their processes, safeguards and methodologies and improve their technology, but real change will likely require some innovative thinking about the entire healthcare environment. One example of such thinking is the so-called “Swiss Cheese Model” of safeguards originally theorised by Dante Ortella and John Reason of the University of Manchester. ⁷ In terms of this model a good system has multiple layers of defence, each compensating for the weaknesses in other layers. Preventable Patient Harm occurs when the different layers share the same flaws (the holes in the cheese line up to go right through).

HOW CAN SOTERIA HELP MANAGE PREVENTABLE HARM?
In a competitive world, hospitals have to keep their shareholder/stakeholders in mind. Unfortunately, the primary focus is often on shareholders and profitability, with patients of secondary importance and employees largely ignored. We would argue that this thought pattern should be reversed – if hospitals take excellent care of their employees, the employees will take excellent care of the patients who in turn will take care of the bottom line. In this spirit, SOTERIA was developed as clinician-focussed software that not only lightens the administrative load on healthcare service providers and institutions, but also improves efficiency and provides several protective layers (helping to stop the hole from going through the cheese). It is an easy-to-use interface with an organized pathway of patient care and documentation that syncs patient data and provides instant access to doctor, nurse and administrator regardless of practice, facility or location. It provides the full clinical patient view, with simple, intuitive prompts that bring pertinent medical information to the point of care. Using SOTERIA, healthcare providers can save time through its optimized medication lists and CPOE features. It is an efficient, easy-to-use interface rendering natural workflows. All information, tests, orders, care plans, guidelines and results are captured, coded, mapped, and saved and will integrate seamlessly across fragmented systems. A flexible reporting function and reliable audit trail provides a wealth of information to management to identify trends, pro-actively plan interventions, as well as measure the efficiency thereof and assist in the defence of possible malpractice lawsuits. The result: better physician support, improved patient outcomes and optimal clinical efficiency.

References:
¹ www.ihi.org
² https://www.who.int/features/factfiles/patient_safety/en/
³ Slawomirski L, Auraaen A, Klazinga N. The economics of patient safety.
Organisation for Economic Co-operation and Development, 2017
https://costsofcare.org/tallying-the-high-cost-of-preventable-harm/
http://www.healthcare.gov/compare/partnership-for-patients/index.html.
⁶ (To Err is Human: Building a Safer Health System, Institute of Medicine,
<.Dickenson, 2000)
https://en.wikipedia.org/wiki/Swiss_cheese_model

Willem Pretorius
General Manager
E: willem.pretorius@infocarehealth.com