Most of the time, people’s experiences as patients, family members, and healthcare providers in the healthcare system are positive. However, at times things do not go as planned.
In Canada and the world, there are significant numbers of people who are harmed or who die as a result of their care and not the treatment process or risks involved. Approximately 1 out of every 18 acute care hospitalizations in Canada in 2014-2015 involved at least one occurrence of harm. Preventable patient safety incidents were the third leading cause of death in Canada in 2013, behind cancer and heart disease. Nearly 1 in 10 children hospitalized in Canada experience a harmful patient safety incident.
Acknowledging that patient incidents do happen is important to taking personal and organizational steps to improvement.
Patient safety involves the complex interaction among institutions, technologies, and individuals, including patients themselves. In other words, patient safety is everyone’s responsibility.
Healthcare providers try to do the right thing, but because they work in complex, imperfect systems with many variables, at times patient safety incidents reach the patient. Some incidents do not cause harm, but others do affect patients - the people health providers are committed to helping.
The tradition and culture of healthcare has been one that suggests that error is unacceptable, and acknowledgement of mistakes is an admission of lack of skill. It has become evident from our successes, and from the experience of harm in healthcare, that this mind set has discouraged the development of a culture that supports learning and improvement.
A key strategy to support learning is to reflect on basic concepts of patient safety, and how you can apply these concepts in your daily practice. Over the next several months we will share this new series, Patient Safety: A Primer, where a key patient safety topic will be highlighted, including questions to stimulate self-reflection. Topics to be covered will be aimed at considering the following questions:
1. How do key human and environmental factors contribute to patient safety?
2. What is a culture of patient safety?
3. What are the key elements of effective patient and family centred care?
4. What are key factors that promote effective teamwork in multidisciplinary healthcare teams?
5. What are key interpersonal and communication skills required for effectively working with patients and families, and within multidisciplinary healthcare teams?
6. What are the major concepts related to recognizing and managing risks to patients in healthcare environments?
7. What are the key elements required in responding to and disclosing harmful incidents?
Learn to be Safe!
For more information on patient safety, go to the Manitoba Institute for Patient Safety website at www.mips.ca or safetoask.ca.
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