November 23, 2015
When the Canadian Patient Safety Institute issued a list of 15 ‘Never Events’ this fall, it signalled a revival of nation-wide attention to address ongoing gaps in patient safety that have plagued the healthcare system since the highly publicized reports of high incidence of preventable adverse events more than a decade ago.
CPSI’s list of Never Events are specific, serious preventable patient safety incidents that result in serious patient harm or death while under the care of a hospital.
Serving as a national call-to-action for patient safety, jurisdictions around the world, including the American National Quality Forum and the English National Health Service, have produced similar lists.
Among the never events listed in the Canadian report are:
The report sets clear targets for hospitals to strive towards, and it is great to see the authors highlight the need for ongoing measurement and evaluation of patient safety incidents.
However, while the publication marks progress in setting a high standard, hospitals cannot only strive to reduce the occurrence of never events and other adverse incidents, but they should set a standard that eliminates all harmful events. Hence, the debate should not be about a reduction target, but about a target of zero.
When we look at other industries’ tolerance for adverse risks, it is always zero. Imagine if the airline industry would aim to tolerate a certain number of accidents per year; passengers would refuse to board a plane. Imagine if the nuclear sector accepted the possibility of one meltdown per decade; there would never be any nuclear plants constructed.
As nearly every one of us will enter a hospital as a patient in our lifetime, we need to be the most vigilant of all industries when it comes to safety. How can a hospital ever tell a patient, and the patient’s family, that we tolerate a certain number of death due to the occurrence of preventable adverse events under our care?
As human factors professionals, it may seem paradoxical that we are advocating for a target of zero when we fundamentally accepts that humans will err, and that those errors can lead to adverse events and harm. But in fact, it is our very knowledge of human fallibility that allows us to frame the design of a resilient system that anticipates, accepts, and mitigates against the inevitability of an error that will harm the patient.
There is also a cultural, behavioural aspect to a zero target. If framed correctly, it can become a rallying call; an aspirational goal for hospital staff, who chose their professional to heal patients, not harm them. This returns them to a place where zero is possible, before preventable adverse events were accepted as matter of fact in the day-to-day of care delivery that was seemingly too complex to address.
In the end, when dealing with a patient’s life and harmful events that are preventable, the benchmark should always be zero, because anything less is not just odd, but is just simply unacceptable from a societal perspective. We remain the only industry that appears to allow preventable adverse events as a matter of course.
That needs to change now.