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Some critical questions for patient safety

Dr Patrick Bolton, Vice President, Australian Healthcare & Hospitals Association, has some further interesting points to make on surgical safety:

“The recent study which showed that the WHO Surgical Safety Checklist reduced postoperative complications by an average of 36% and resulted in a fall in the total in-hospital death rate from 1.5% to 0.8% takes one in a number of directions.

The first is that some parts of Australia already have a preoperative “time out” procedure during which matters important to patient safety are reviewed. The procedure was introduced in NSW in order to ensure “right patient, right side, right site” surgery.

This is ironic because the chances of being subjected to wrong site surgery are less than one in one hundred-thousand. It seems that we already have a checklist, but it may not be looking at the most important areas. This seems silly.

The WHO Checklist is to be welcomed because it has been shown to make an important difference to patient safety. It can be built on top of existing practice to enhance it.

The second fact is that the overall death rate in Australian public hospitals in 2006-7 was 1.3%. This puts Australian hospitals ahead of the baseline performance of the study hospitals, but behind their performance after introduction of the WHO Checklist.

Professor Chris Baggoley, Chief Executive, Australian Commission on Safety and Quality in Health Care, says that Australian hospitals are already doing many of the things on the WHO Checklist. This means that there must either be important parts of the Checklist that Australian hospitals have yet to implement, or important changes that they could make in other areas of care so that they are achieving at the level of the study hospitals after the Checklist had been implemented.

The further 0.5% reduction in in-hospital death which might be achieved represents around 22,000 preventable deaths annually, over ten times the national road toll.

The third point is that, death rate aside, it will be difficult for Australians to detect the impact of the introduction of improvements such as the WHO Checklist because we are not quantifying adverse outcomes in our health system.

A 1993 study found that 16.6% of Australian hospital admissions were associated with an “adverse event”, and in 4.9% of these cases the patient died. These figures are comparable with those in other Western nations.

Significant investment has been made in quality improvement in healthcare across Australia. Unfortunately the impact of this investment is unknown because the study has not been repeated.

Like the “time out” procedure above, important initiatives are being implemented in suboptimal ways. We can’t know if we are making things better if we don’t measure them.

Finally, change of this kind is not easy, a point made by the HARC eBulletin from the Sax Institute which seeded this blog. A lot more is known about what works than about how to put it into practice.

It is important to support Australian hospitals to implement reform to meet world’s best practice. Moving to a different governance model for the Australian healthcare system is being discussed by some commentators.

Improving the current model through initiatives such as the WHO Checklist may be less risky and more efficient and should be considered as one of the alternatives.

To this end, I would commend to all stakeholders interested in how Australian compares itself accurately with the rest of world to attend the AHHA Congress 2009 in Hobart, Tasmania from 7-9 October.

All of these issues plus more will be addressed, including practical benchmarking sessions along with improving the Australian health system in all areas and how best to achieve this.”

Comments 2

  1. John Sullivan says:

    Tick the Box Medicine
    The National Health and Medical Research Council (NHMRC) is revising its’ guidelines for infection control in health care. One potentially revolutionary finding which may find its’ way into the new guidelines is the checklist idea advocated by Peter Pronovost and associates. The checklist study was conducted in 2006 and is currently referenced on the guideline revision wiki page of the Healthcare Infection Control Special Interest Group, who consulted with the NHMRC on the review. The study included 103 hospitals and demonstrated that using a five item evidence based hygiene checklist for inserting a central venous catheter produced a sustained 66% decrease in bloodstream infections from baseline after 18 months. Associated with this reduction was an estimated saving of one hundred and seventy five million USD and one and a half thousand lives. These are some of the most significant reductions in catheter associated infection rates since the rise of antibiotic resistant bacteria, and all achieved by the simple expedient of ensuring that basic steps like hand washing, gowning and gloving before inserting a catheter are followed consistently.
    Yet as Pronovost himself acknowledges, implementing a simple checklist is far from easy. In the experience of the study team it requires open communication at every step, coordination of management, staff and adequate logistical support. Perhaps the most challenging factor however is that adoption of the checklist was found to require a cultural shift. One feature of the project was that nurses were empowered to stop doctors who missed a step on the checklist and make them start over; an innovation which many doctors, rightly or wrongly, may believe has the potential to undermine the doctor patient relationship, causing a loss of face and possibly creating an undercurrent of antagonism between doctor and nurse. Logically these hypothetical objections should carry little weight in the face of a demonstrable saving in both lives and money, but rarely is pure logic the force it should be in the decisions of individuals and organisations.
    As Pronovost freely admits, such objections matter a great deal in his experience, and must be addressed if a checklist is to be successfully implemented. They are not insurmountable as the success of the 2006 study attests, and they should be surmounted given the enormous benefits that can potentially be reaped. In the example above a simple and obvious remedy would be to restructure the nurse-doctor interaction to be more overtly cooperative. A nurse or intern could simply read out the checklist as the procedure in being performed, giving doctors the opportunity to respond or acknowledge, in much the same way that a pilot and co-pilot interact when they run through a takeoff or landing checklist. This avoids any undertone of antagonism or conflict, in contrast to the situation where the checklist holder looks silently on, ready to pounce on any error.
    Some doctors have more concrete objections to the checklist, they view it as redundant, insulting and yet another example of the bloated medical bureaucracy, because hygiene standards are perceived to be of a high level already. In fact studies have shown that, in a busy and stressful intensive care unit, errors in hygiene can run as high as 30%. Such errors are often neither noticed nor remembered because they are typically made when staff are busy or distracted, as is often the case in hospital work. Unlike a surgical error if you make a hygiene error most of the time there will be no obvious consequence. The patient will not usually become infected and the minority of times when they do symptoms will manifest days or even weeks later. Cause is separated from effect and people just aren’t good at connecting the dots in these sorts of scenarios with the result that no lack of standards is perceived. Yet due to systemic factors such a time pressure and the stressful nature of hospital work these errors do happen, and the checklist is an effective way of ensuring that they do not.
    The potential applications for evidence based checklists in medicine are vast. They can potentially be used not just for procedural tasks, but for diagnosis and ongoing management as well. However, it is easy to visualise a scenario where doctors are swamped in checklists with no consultation, follow up or logistical support. Introduction of even one checklist protocol without such supports is likely to fail, and if the NHMRC does decide to recommend their use, they will need to further recommend that adequate human and other resources are provided to maximise the chance of a successful introduction.

    – John Sullivan.

  2. Sam says:

    Is the evidence for surgical checklist conclusive?

    A critical review of the paper presenting the findings from the WHO pilot study on surgical checklists (1) questions the value added by surgical checklist to Australia and other high-income countries. Of the four sites in high-income countries, only one site showed statistically significant improvement in outcomes following implementation of the surgical checklist. Yet, this site did not change practice for the better as a result of the intervention. It is also not clear from the paper whether income-level of country was adjusted for as a confounder of the causal relationship. We must then ask ourselves, is there conclusive evidence that surgical checklists in high-income countries are effective in improving patient safety?

    The point of drawing ones attention to these methodological issues is to highlight the importance of evidence in policy making. It appears from discussions that there is no up to date baseline measure in Australia to quantify the problem of surgical error. John Sullivan has alerted us to some of the difficulties of implementing checklists in medicine.

    If our agenda is to improve patient safety, it is necessary to develop policy based on evidence.

    References
    1) Haynes AB et al. “A surgical safety checklist to reduce morbidity and mortality in a global population” N Engl J Med 2009;360(5):491-9.

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Pregnancy and childbirth
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#CTG10
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Acknowledgement
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Uluru Statement
WA community closures
News about Croakey
PIJ Commissions 2021
Public health and population health
#PreventiveHealthStrategy
#UnmetNeedsinPublicHealth
air pollution
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COVIDwrap
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Health in All Policies
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Media Doctor Australia
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Summer reading 2020-2021
Tasmanian election 2021
Testing Croakey News category 1
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Croakey Conference News Service 2013 – 2019
2013 conferences
Australian Centre for Health Services Innovation Forum 2013
Australian Health Promotion Association Conference 2013
Closing the Credibility Gap 2013
CRANAplus Conference 2013
FASD Conference 2013
Health Workforce Australia 2013
International Health Literacy Network Conference 2013
NACCHO Summit 2013
National Rural Health Conference 2013
Oceania EcoHealth Symposium 2013
PHAA conference 2013
2014 conferences
#IPCHIV14
AIDA Conference 2014
Congress Lowitja 2014
CRANAplus conference 2014
Cultural Solutions - Healing Foundation forum 2014
Lowitja Institute Continuous Quality Improvement conference 2014
National Suicide Prevention Conference 2014
Racism and children/youth health symposium 2014
Rural & Remote Health Scientific Symposium 2014
2015 conferences
#CPHCEforum
#CRANAplus15
#HSR15
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Population Health Congress 2015
2016 conferences
#AHHAsim16
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#ATSISPEP