Quality in health care: patient safety
One of the definition of the quality is that doing something excellence or degree of excellence in specific field [1]. Inappropriateness of the Quality Control and Quality Assurance model which focus on inspection created need for more comprehensive model which called Total Quality Management (TQM) in Manufacturing Industry. As a comparison to the previous approaches, TQM is more comprehensive, participative and preventive. Changes and improvements in manufacturing, aviation and nuclear industries have led health organizations to provide safer care for their patients. Several institutions and studies identified six dimensions of quality in healthcare [2, 3]. They are safety, efficiency, access (timeliness), efficacy, equity (appropriateness) and patient centeredness (consumer participation). One of the high quality of healthcare indicators relies on safety. World Health Organization (WHO) defined patient safety as “the absence of preventable harm to a patient during the process of healthcare” [4].
Unsafe events and their categorizations
Previously, medical incidents were called errors and medical errors can refer to 'wrong action or failures in planned care' or 'implementing wrong care plan to the patient'. Furthermore, medical error was defined as “an unintended health care outcome caused by a defect in the delivery of care to a patient” by National Patient Safety Foundation in Australia [5]. More recently, errors have started to be called as “unsafe events”. Broader understanding of unsafe event’s etiology and better classification of the unsafe event were done by psychologist James Reason (Fig. 1). Recent International Forums on Quality and Patient Safety in Healthcare and Institute for Healthcare Improvement (IHI) have taken up those understanding and classification of unsafe event that help providers for better understanding of unsafe events.
Safety issues are more likely to occur in intensive care units, operating rooms and emergency services [5, 6]. In addition to these safety problems there are non-clinical issues which considered as operational risk factors such as: manpower, medical supplies- product quality, patient transfer, occupational safety and health (OSH), facilities defects, data security & confidentiality, equipment failure, hospital security, fire safety and financial issues [5].
After IOM report released in 1999, most of health care organizations focused to prevention of medical errors however experts from most recent safety forums have suggested understanding of why these unsafe event occurs in health industry. In order to prevent errors and harm, professionals should understand error causation to prevent these unsafe events and address complex issues in system. Psychologist James Reason, to facilitate learning and identifying, he defined unsafe acts via dividing them to four groups: slips, lapses, mistakes, and violations (Fig. 1).
Unsafe act can be error or a violation that committed in the existence of a potential risk [7]. According to WHO, violation is defined as “a deliberate deviation from an operating procedure, standard, or rules” however such violations may occur and the intentions may not be causing harm [8]. Errors are whether mistakes (rule based, knowledge based), lapses or slips. Human failures are an actions that may “not go as intended” or “go as intended, but it is wrong”. For the action that doesn’t go as intended, it might be observable slip or unobservable lapse. On the other hand, action which goes as intended but it is wrong, so called as a mistake that involves failure in planning process. Mistakes are either rule based which provider has knowledge but applies it wrong or knowledge based that provider doesn’t have required knowledge for responding.
The shift in approaching and understanding of patient safety issues
The previous perspective for underlying factors of unsafe event focused to complexity of the health system and blamed individual (providers) for causing errors. After several researches and evaluations were conducted, professionals saw that blaming, naming and shaming approaches do not help to improve patient safety outcomes. After 15 years of IMO report, when providers were being understood that they do not intend to cause harm on patients, then the perspective has started to shift from individual level to system failures. They realize that most errors cannot be linked to the individual performance and these issues are mostly results of a series of preventable system errors. Redesigning systems to prevent errors and violations may help healthcare organization to improve the system and have better human condition and the conditions under which humans work.
Human factors and changing behaviors of providers
“Human factors” are discipline of engineering that deals with the interface of people, equipment, and the environment in which professional perform their duties. There are internal and external factors that affect human performance. These several circumstances influence human performance and increase risk of occurrence of unsafe events. Mental and physiological states, such as: fatigue, stress, dehydration, hunger, and boredom are playing role before the unsafe event occur. On the other hand, perception, attention, memory, reasoning, and judgment directly influence decision making process. Lastly, communication and being able to carry out the intended action are factors that directly increase possibility of decision execution.
Behaviors of provider may play essential role to improve safety for patients. Absence of safe behaviors in healthcare can lead to patient harm. The way to prevent errors is not to tell people to be more careful and work harder, it is changing the systems in which they work. As James Reason’s teaching of latent errors: those “accidents waiting to happen” because of defects in the design of the systems in which people work. So that, WHO suggests using human factors principles to understand relationships between humans-humans, humans-medical equipment and humans-environment [9]. Well designed processes may make it easy for people to do the right things, and hard to do the wrong things. Multiple factors, which affect ‘brain processes and responds’ and influence ‘personal performance’ negatively, need to be prevented and mitigated for intended safety outcomes.
Critical behaviors of healthcare staff: speaking up!
There are four critical behaviors which are under our control that help to improve patient safety. They were classified by IHI as [10]:
Joint Commission predicted that 80 % of the serious safety events occur due to miscommunications among professionals. ‘Speaking up’ is one of the critical behaviors of patient safety that both provider and patient have ability to improve it. It is defined as raising of concerns by professionals or patients in existence of recognized deficient or risky actions that affect patient safety and quality of care [11]. It may display essential role in preventing and mitigating unsafe event which is causing harm on patient.
Public health significance
According to the IOM report in 1999, medical errors cost $29 billion and least 44, 000 people; however more than 98,000 deaths occur as results of medical errors every year and burden of the medical errors exceed the sum of the burden of vehicle accidents, breast cancer and AIDS in the United States [6, 12]. Some studies present that 1 in 3 Americans have experienced medical incidents while seeking care for their selves or their relatives [13].
Apart from US, WHO highlighted that [14]:
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Almost, 1 in 10 hospital patients is harmed while receiving care in developed countries.
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Hospital infections influence 14 of every 100 hospital admissions. As a result, 1.4 million people suffer from hospital-acquired infections in the world.
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Unsafe injections can cause 1.3 million deaths every year.
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In some countries, as many as 70 % of injections are done with unsterilized syringes or needles.
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Poor quality in healthcare could result with 20 % - 40 % waste. So that, studies demonstrate that improving patient safety could save some countries between $6 and $29 billion annually.
Safety events may occur between 3.7-16 % and avoidable harm expected to be 10 % of events [15]. In one of the survey (n: 192,462), results showed that 53 % of professionals afraid to raise a question when something did not seems right during procedure [16]. Unsafe events are not just causing lost income, household productivity, physical and psychological discomfort on patient but also resulting with such impacts on caregivers, providers and patient families. Healthcare organizations should seek solutions to mitigate these unsafe acts for better safety outcomes and ensure that their patients are safe during admission, diagnosis, treatment and discharge processes.
Objective
The objective of the literature review is to determine the evidence of the role of “speaking up” as a safety behavior in healthcare.
