Patient safety at the heart of healthcare

Achieving improvements in patient safety has always been a core goal of the College of Anaesthesiologists of Ireland and will be highlighted at its upcoming conference

The College of Anaesthesiologists of Ireland (CAI) has prioritised excellence in patient safety and quality-of-care as its primary strategic aim within its strategic plan (2019-2024). The ambition of the College is not only to advocate for patient safety, but to be a national and international leader driving the patient safety agenda. The importance of patient safety promotion and leadership is internationally agreed. At the 72nd World Health Assembly in May 2019, all World Health Organisation (WHO) member states moved to recognise patient safety as a global health priority.

In advocating for countries to take measures to improve patient safety, the WHO cite some well-known, but still stark figures:

• Adverse events in healthcare is one of the 10 leading causes of death and disability in the world;
• Every year, 134 million adverse events occur in hospitals in low- and middle-income countries (LMICs), resulting in 2.6 million deaths;
• In high-income countries, approximately one in every 10 patients is harmed while receiving hospital care, with around 50 per cent being preventable;
• In OECD countries, 15 per cent of total hospital activity and expenditure is a direct result of adverse events.

Unfortunately, Ireland fits neatly into this data pattern. The 2016 Irish National Adverse Events Study (INAES) revealed an adverse event prevalence of 12.2 per cent of Irish hospital admissions – 70 per cent of events were preventable, and they contributed to substantial disability in approximately 10 per cent of those affected, and death in 7 per cent. From this, it is obvious that systemic and sustained efforts at reducing patient harm could not only lead to the absolutely desirable effect of better patient outcomes, but also result in significant financial savings that could be used to improve and accelerate the care of other patients.

History

If we understand patient safety as a discipline that aims to prevent and reduce risks, errors and harm that occur to patients during provision of healthcare, then anaesthesiology has a long history of attempting to improve outcomes through the critical examination of its own practice. The first ether and chloroform anaesthetics were administered in 1846 and ’47 respectively and it did not take long before the mortality rate from anaesthesia became the subject of intense debate and public discussion.

As a result, three commissions of inquiry were established between 1888 and 1893 to examine the safety of anaesthesia. The last of these, The Lancet Commission, focused attention for the first time on the role of human error in the aetiology of anaesthetic deaths: “From the evidence before the subcommittee they are convinced that by far the most important factor in the safe administration of anaesthetics is the experience which has been acquired by the administrator.”

Fifty years later, Robert MacIntosh, the first Professor of Anaesthesia, reiterated concerns and contended that deaths continued to occur at a high rate primarily because of faulty techniques, poor training and inadequate supervision. And so, in 1949, the Association of Anaesthetists (ASA) (Great Britain and Ireland) set up a voluntary recording scheme of anaesthesia-related deaths and six years later published an analysis of the first 1,000 cases submitted.

The committee charged with analysing the fatalities also identified “a lack of skill, poor equipment and insufficient medical or nursing supervision” as the overriding factors that led to many of the deaths. The results of this ‘audit’ by the Association set in motion systematic attempts in the development of better drugs and techniques, and the implementation of more rigorous standards of training, education and assessment.

Perioperative patient safety

Since the development of anaesthesia as a recognised specialty, anaesthesiologists have always sought to lead in efforts to improve perioperative patient safety, perhaps because of the obviousness and immediacy of the harm that an error can bring. The results have been impressive. Anaesthesia-related mortality, which was estimated to be 1/1,000 cases in 1982, had fallen to <1/100,000 by 2005 across Europe, Australia, and North America. And, while safety data indicates that hospital care remains hazardous for patients, anaesthesia for ASA physical status I and II patients undergoing day case surgery is now considered to be in the ultra-safe zone. It is one of the safest and most reliable procedures that a patient can have.

There is no space for complacency. While now much perioperative morbidity and mortality relates to the complexity of the procedure and/or the frailty of the patient, avoidable episodes of harm continue to occur. There remains a need to relentlessly drive up standards by understanding what we do well in the majority of cases and replicating it, by studying harm episodes and learning from them, and by implementing change aimed at continuous improvement.

As the largest single in-hospital medical specialty involved in the care of approximately 60 per cent of all patients admitted to hospital, and trained in a particular set of skills that are especially focused on enhancing and protecting the wellbeing and welfare of the patient, anaestheologists are in a particular position to lead by example. There are some clear areas to be focused upon. Operating theatres should become places where a culture of safety dominates, where the environment allows all healthcare providers to speak out, where everyone is an advocate for patient safety.

There is a need for a continuous cycle of practice assessment, evaluation and reflection that drives changes that enhance patient outcomes. And perioperative communication must be improved upon – failure of effective communication remains the primary factor in the majority of healthcare adverse events. While there are commendable independent and local efforts aimed at achieving some of these goals, there is a need for a more central and coordinated perioperative safety strategy.

According to Dr Brian Kinirons, President of the College of Anaesthesiologists of Ireland, the College’s aim “is to drive patient safety policy through five main domains: Education and training, audit, external engagement, leadership, and global health. The first of these is already a core pillar of the anaesthesia training programme, with a particular focus on non-technical skills, human factors and professionalism.” However, Dr Kinirons recognises that there is a need to broaden these applications.

“The CAI patient safety strategy includes ambitions to further develop training in the fundamentals of patient safety relevant to the perioperative environment – to expand collaborative multi-disciplinary training through simulation,” he said.

“Simulation will enhance engagement with our anaesthetic nursing and surgical colleagues. Elements of safety training could, and should, be incorporated into undergraduate healthcare education and be a focus of continuing professional development.

“It must be noted though that most of the gains in patient safety have occurred in developed countries, with little change happening in low-and-middle income countries because of deficiencies in staff, expertise, technology and medication availability. The College has an ongoing engagement with CANECSA (College of Anaesthesiologists of East, Central and Southern Africa) with a view to targeting the training of anaesthesiologists in areas with the least availability of anaesthesiologists per million of the population.”

The CAI has recently appointed Dr Barry Lyons as its Director of Patient Safety and Quality Improvement. Dr Lyons stated: “Patient safety is a curious thing. Any clinician offered a drug or treatment that would radically improve the outcome of 10 per cent of their patient population would be likely to jump at the chance. But there is no magic bullet that can make patients safer, and certainly nothing that is particularly high-tech. Instead, most of the interventions that could reduce adverse outcomes to this degree are within our grasp and are largely low cost.

“What is required to make substantial gains is the genuine desire of all healthcare professionals to prioritise safety for patients, to adopt a collegial and collaborative approach, to embrace education and reflection on safety in an undoubtedly complex system, and to make a considered effort to evaluate and reduce the risks created by systems and practices.”

“A deficiency in perioperative patient safety is not something that can be solved by external agents, but by those who work within a theatre complex. However, visible leadership from the relevant Colleges can certainly help, along with networking with other groups that can provide relevant feedback in the form of audit data, information from investigations, inquiries or litigation, and responses from affected patients,” said Dr Lyons.
“The College of Anaesthesiologists of Ireland proposes to curate this information, and to assist clinician investigators and others to acquire, develop and disseminate new knowledge and management techniques that can improve patient safety. The proposed domains and goals align with those set out in the Irish Medical Council’s mission statement, the patient safety and advocacy policy promulgated by the Department of Health, and the strategic approach of the HSE (By All, With All, For All: A Strategic Approach to Improving Quality 2020-2024).”

According to Mr Martin Mc Cormack, CEO of the CAI: “The developed world of anaesthesiology has made significant strides in its goal of eradicating avoidable perioperative mortality and morbidity, but there remain significant problem areas relating to both practice and geography. There is an ongoing need for all perioperative professionals to build towards a culture of patient safety in their environment I am grateful to the Council of the College of Anaesthesiologists for prioritising investment in education and training to improve patient safety.”

Dr Kinirons added: “As part of our commitment to increase public awareness and engagement, enhance global understanding, and spur global solidarity and action to promote patient safety, Dr Lyons has spearheaded a world class national patient safety in anaesthesia conference due to take place on 13 November 2020.”

“We look forward to hearing from leaders in patient safety and quality improvement such as Dr Dorothy Breen, Dr Amy Donnelly, Dr Emma Cunningham , Prof Andrew Smith, Dr John Fitzsimons, and Dr Stephen Drage, focusing this year on rescuing the deteriorating patient, safe prescribing, post-operative cognitive events, and promoting shared learning.”

For further details, please see: https://www.anaesthesia.ie/latest-news/national-patient-safety-in-anaesthesia-conference-friday-13th-november-2020/

This article was produced by the College of Anaesthesiologists
of Ireland.