Book Review

Safer Hospital Care

The book endeavours to convince readers how care providers can sniff out unsafe work practices in hospitals and innovate elegant and comprehensive solutions

‘Medical errors may be unpreventable, but preventing harm to the patient is often an option’. Patient safety is elemental to Hippocratic Oath and fundamental to quality in healthcare. Improving patient safety, reducing medical errors and providing comprehensive quality care is a challenge faced by healthcare organisations globally. From newborns burnt alive in the incubators, radiation overexposure to medication mix-ups and hospital-acquired infections, one is all too familiar with such grim accidents happening routinely in Indian hospitals. No hospital has yet succeeded in implementing all the 34 safety protocols recommended by National Quality Forum.

Paradoxically, healthcare continues to be decades behind other industries in terms of creating safer systems. Errors in healthcare are usually provoked by weak or inadequate systems within and across healthcare organisations. These events often have common root causes which can be analysed, generalised and corrected. Patient safety requires well designed work flows, processes and robust systems for delivering healthcare services. Therefore, improving safety and reducing errors is a challenge faced by hospitals all over the world.

Contents and Key Concepts

The book endeavours to convince readers how care providers can sniff out unsafe work practices in hospitals and innovate elegant and comprehensive solutions, usually at very low or no cost. Safety is a function of dynamic system, communications among interfaces such as patient hand offs, technology and information systems, interactions and complex influences of components throughout the healthcare ecosystem.

The author argues that healthcare, like aviation, needs to build up a culture of measuring and improving performance, promoting safety and teamwork to prevent and mitigate errors. Healthcare heavily relies on the “weak aspects of cognition” (short term memory, attention to details, vigilance, multitasking etc.)

The author defines unsafe work; explains why the chances of error are higher in hospitals and how unsafe work propagates unknowingly. He goes on to argue how disengaged employees, insufficient understanding of system vulnerability, splitting tasks amongst many care providers makes system error prone. Ineffective risk management methods, often touted as ‘best practices’, are like a bad virus with long incubation period and no early warning resulting into sudden catastrophic accidents. To reform hospitals and healthcare, one must recognise that they are highly dynamic systems that must be fixed systemically. Safe hospital care is not just about doing things right; it is also about breaking old habits, finding new tools, and doing the right things to the right patient-every time.

The author discusses the barriers and safeguards to prevent harm impacting patients by applying human factors engineering principles like crew resource management, use of checklists, safety techniques like management oversight and risk tree, Swiss Cheese Model and mistake proofing. Until a decade ago it was believed that healthcare is unique and principles and efficient and safe practices of other sectors cannot be applied to healthcare. But the author challenges these assumptions and advocates borrowing ideas from other high reliability industries like aerospace, Toyota Production System and Disney Resorts for achieving delightful patient experience and earning their loyalty and to instill factory like efficiency into healthcare. He avers that using systems and heuristic approach to safety management can reform healthcare He argues that to maintain equanimity and exercise emotional intelligence by care providers is as important as applying technical skills.

Thus, there is an urgent need for a paradigm shift in healthcare to enhance quality, safety, and reliability through powerful applications of human factors to optimise the relationship between man and his working environment. Supported by case studies as well as inputs from such paradigm pioneers as Johns Hopkins, Veterans’ Affairs, Allegheny General and Seattle Children’s Hospital, the author explains how to:

• Learn the science of safe care in a systemic way
• Adapt evidence-based safety theories and tools taken from the ultra safe industries like aerospace, nuclear, automotive and chemical industries
• Identify the combination of root causes that result in an adverse event
• Apply safety management and analytic tools and techniques like FMEA,Fault Tree Analysis and Vulnerability Hazard Analysis that can effectively measure hospital efficiency
• Eliminate waste, redundancy optimise resources and simplifying processes
• Establish evidence between lean strategies and patient satisfaction
• Make use of various types of innovation, including accidental, incremental, strategic, and radical, and establish a culture conducive to innovation
• Non punitive incident reporting system and establish blame free culture
• Gain competitive edge and create high value through institutionalising innovation in healthcare
• Working in effective teams with collaborative communication to deliver safer care achieving higher ROI by continuous innovation
• Identify matrix of biases and pitfalls that can lead to inaccurate diagnosis and suboptimal care
• Speak up against the unsafe practices and change the system
• Reinvent risk management since quality and risk management are interdependent on each other

The USP of this book is its comprehensive and in depth approach towards safety management and informal style of narrative, freedom from medical jargon, borrowing innovative ideas, elegant solutions and safe practices from other industries. It liberally quotes management gurus and draws from experience of these boundary spanners and paradigm pioneers. Further, with prompting from groups such as the IOM, Joint Commission for Accreditation of Healthcare Organisations, The Leapfrog Group, Institute of Healthcare Improvement, The Agency for Healthcare Research and Quality, and others, the author is able to build up a compelling case for care providers to mitigate errors and improve patient safety.

Patient Safety in India

The Indian healthcare sector is currently undergoing transformation and can learn a lesson or two from US healthcare industry by not repeating the same mistakes. In keeping with the commitment to patient safety, the MoHFW, GoI has mandated, AIIMS in collaboration with the WHO & INCLEN Trust to take forward the “WHO- Global Patient Safety Challenge” by launching the National Initiative on Patient Safety on September 14th, 2009 and drafting a patient safety policy. National Accreditation Board for Hospital and Healthcare Providers (NABH) has incorporated patient safety performance in its standards. Few hospitals have started with patient safety initiatives like incident reporting, analysis of sentinel events, training and education programme for the employees and students. However, most hospitals continue with a fragmented or ostrich like indifferent approach oblivious to the issues of patient safety.

Target Audience

The book is well designed for use in courses of healthcare and hospital administration, patient safety/quality assurance officers and assessors, medicine and nursing and in general for all those interested in promotion of patient safety in hospitals and healthcare organisations. Healthcare providers without medical background shall find it as readable as super specialists and can use the book effectively, either as a general reference or by focusing on the conceptual and applied material as a framework for achieving safer and quality healthcare in their organisations.

(Gp Capt (Dr) Sanjeev Sood is a Hospital Administrator and a NABH Empanelled Assessor. doc_ssood@yahoo.com )