Jan 18, 2010

We must end the silence surrounding the risks of health care

A few years ago, a group of American activists set out to protect millions of human lives; not from global scourges such as malnutrition or preventable disease, but from the ravages of the world's most expensive and sophisticated health-care system, that of the United States of America.

The ''Five Million Lives - Let's Make Harm History'' campaign was not a tasteless First-World parody of Third-World misery, but a serious effort by the non-profit Institute for Healthcare Improvement (IHI) to draw attention to the considerable risks of harm and death caused by modern health-care systems.
For all the extraordinary advances in medical science and technology, getting sick (or injured) is a safety issue.

Worldwide, health-care errors cost an incredible 10,000 disabilities and deaths every day. Today's patients have only a one in two chance of receiving recommended care, a 1:10 likelihood of something going wrong in hospital and a 1:50 possibility of a health system-induced death or major disability. And that's in the world's best resourced health systems, such as US and Australian hospitals.
Prime Minister Kevin Rudd acknowledges Australia's beleaguered health system has reached a critical ''tipping point''. Last year's landmark National Health and Hospital Reform Commission report argues for new funding and administration models to address, among other pressing issues, the shortfall in the delivery of appropriate care.
Yet for all its 123 recommendations, the commission's report contains mostly high-level pronouncements, when much depends on driving change at the troubled health-care ''coal face''.
Complex systems fail for many, inter-related reasons. Ensuring heart surgery is skilfully performed or the right dose of radiotherapy is calibrated and delivered depends not only on individual competency and focus, but on every one of the multitude of human interactions in long treatment chains. Modern health care can be delivered only by well co-ordinated teams, but team work is routinely compromised by fatigue, heavy workloads and inadequate resources.
Technology offers one path to safer hospitals. Take the video surveillance equipment installed on state order in the operating theatres of a US Rhode Island hospital recently, after its fifth ''wrong site'' surgical procedure. In three cases surgeons had operated on the wrong parts of the brain.
But technology is just a tool. Reducing errors is as much a matter of admitting just how serious the problem is. We have managed to join up the dots in other areas where individual suffering adds up to a threat to community safety such as signs outside coal mines declaring the number of ''accident-free'' days or the grisly images on cigarette packets. Health professionals wholeheartedly support such frank disclosures. But, on health system risks and harm there is relative silence.

Recent lessons from the mining and aviation industries suggest that professional attitudes really do matter. By openly acknowledging that ''things can go wrong, and will go wrong, so we need to be very vigilant'', mining companies and airlines have shifted safety to the top of their organisational agendas.
The idea that hospitals and other health care providers should publish details of patient deaths and avoidable harm may well be resisted. Health care professionals are trained to face disease, injury and death with heroic, rational cool. But what we really need are clinicians who are prepared to admit they are fallible - especially under system-wide pressures - and to own up when they make mistakes.

Internet-driven consumer activism is exposing health-care risk anyway. US health consumers can already check out the ''grades'' of thousands of hospitals and hundreds of thousands of doctors online, and online forums mean few health-care tales go untold.

Far better would be accurate, standardised safety benchmarks. Medical care will always be risky, but health systems cannot be effectively reformed without open incident reporting, which avoids blaming individuals and enables complex systems to learn from their errors.

In such ''safety-first'' cultures practical measures work. The successful ''Five Million Lives'' campaign was built, for example, around washing hands more frequently to tackle known risks of hospital-acquired infections, adopting better procedures in operating theatres, reducing critical delays in life-saving treatment and the administration of correct drugs and dosages. International efforts to build global health safety standards and procedures, backed by the World Health Organisation, are also promising.
Interestingly, data suggests patients and families are less likely to sue if they believe an adverse medical outcome was a genuine, unintended error, if the doctor or health care worker apologises and if remedial action is taken so ''it can't happen to someone else''.

The Rudd Government's much anticipated health reforms, due out soon, are also most likely to succeed in an open disclosure health system. With a federal election approaching, both sides will be positioning for a policy bunfight over our votes. This seems like an ideal time for our own ''make harm history'' health-care campaign.

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