“To Err is Human: Building a Safer Health System” – this is the title of a report published by the American Insti- tute of Medicine in 1999, which analysed and aggregated a large number of studies and measurements of patient safety. The results created a sensation all over the world. According to these, between 44,000 and 98,000 people in the US die every year as a result of medical malpractice. The report made a major contribution to the fact that problems with patient safety, which were actually known, have since been addressed considerably more system- atically and consistently. However, it remains a permanent challenge, not least because the art of medicine is changing constantly due to new technologies and findings, and healthcare professionals have to keep adapting to this. The Foundation for Patient Safety estimates that 700 to 1,700 deaths occur every year in Switzerland due to mistakes made in in-patient healthcare.
ERROR-RESILIENT SYSTEMS
There is general agreement that mistakes in healthcare are not simply made by a few “black sheep”, but by well-trained, experienced, and motivated staff. Because the adage “to err is human” applies to medicine as well. However, there can be no doubt that the system in which medical staff are integrated has a major influence on the probability of mistakes. An error-resilient system antici- pates possible mistakes such as mix-ups, forgetfulness, misunderstandings, or wrong decisions under pressure of time, and counters them preventively with suitable pre- cautionary measures. These include, for example, system- atic follow-up checks and counterchecks using binding checklists, rules for communication, documentation, and the exchange of information as well as regular training.
PATIENT SAFETY AT HIRSLANDEN
Hirslanden has been using a large number of such instru- ments spanning the group for many years. Some of these have already been mentioned in the preceding pag- es, for instance the hygiene guidelines. One of the most important instruments is the WHO Surgical Safety Checklist. This checklist is used before each operation to once again check points that have apparently been clari- fied: once before inducing anaesthesia, once before the surgeon makes the first incision, and finally before the patient leaves the operating theatre again. The purpose of this checklist is, inter alia, to prevent mix-ups, for exam- ple the wrong side of the body, wrong part of the body, or even the wrong patient. International studies estimate that mix-ups in operating theatres occur with a fre- quency of 1:27,000. In terms of the hospital landscape in Switzerland, this means several dozen cases every year.
Another place where mistakes or other unforeseen events are particularly critical is the intensive care unit. This is why ever more Hirslanden hospitals have special emergen- cy teams, so-called Rapid Response Teams or Medical Emergency Teams. They are on duty 24 hours a day and are ready to help on site within a set period of time. Furthermore, one of the most common and consequential mistakes in medicine is made when handing patients over at the interface in medical care. For this reason, Hirs- landen relies on standardised communication methods that are specifically customised to such handover situa- tions. This also applies to the exchange of information across various hierarchy levels, such as between doctors and nursing staff. Another area that is susceptible to errors is medication because an average of 50 to 100 pro- cess steps lie between a doctor prescribing a drug and the patient receiving it. Drug safety at Hirslanden is ad- dressed by a sheaf of measures. These range from the dual control principle and, in some cases, computer-assist- ed medical prescription to standardised drug labelling.
CONSTRUCTIVE ERROR CULTURE
Hirslanden continually develops and defines the instru- ments for patient safety by integrating the latest findings into the implementation of the rules and methods. Above all, however, Hirslanden defines a structured procedure on how to learn from critical incidents in order to derive additional preventive measures from them. For instance, case conferences (Mortality and Morbidity Conferences) at which cases with difficult courses or errors are analysed are regularly held at the Hirslanden hospitals. The aim of this is to find out which precautions must be taken in future to prevent the same undesirable incidents. This error culture is also a foundation stone of the safety information system (SIS) that has been used at all Hirs- landen hospitals since 2008. It offers staff members in all occupational groups the possibility of anonymously reporting errors that might have led to harmful incidents. This procedure is based on the knowledge that every actual harmful incident is preceded by several hundred
so-called critical inci dents. The cases reported to the critical incident reporting system (CIRS) are categorised and analysed, and processed by an interdisciplinary committee at each hospital. This analysis is centred on two questions: “Why did the system allow this critical incident to occur?” and “How can the system be modified or amended to prevent the same critical incident hap- pening again?”
According to the principle of learning from one another, Hirslanden has institutionalised the exchange of expe- rience among the hospitals. The hospitals present their cases to the other hospitals at regular SIS meetings and discuss the preventive measures derived from them. Although these sometimes concern what seem to be mere details, these may be very important at decisive mo- ments. Examples of this include placing materials where they are more convenient, or introducing dual controls at interfaces in the healthcare process.
Classification of critical incidents, in percent
20.8% Resource staff 18.3% Communication/Information 16.9% Medication 16.4% Processes 14.6% Behaviour 6% Material/Equipment/IT 3.4% Diagnostics/Treatment 1.8% Workplace 1.7% Patient
CRITICAL INCIDENT REPORTING SYSTEM (CIRS)
The diagram shows the respective proportions of the various categories of critical incidents in 2013.
20.8% 18.3% 16.9% 16.4% 14.6% 6% 3.4% 1.8% 1.7%