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The Big Numbers of Patient Safety

The Big Numbers of Patient Safety

It is important to first explain the numbers of Patient safety, to see the structure of the topic, its main factors and the weight that each one has on the total. After signaling the problems, we will define the work objectives and possible solutions. The numbers guide us and help us define our priorities.

The differences in service quality between some economic sectors are surprising, and they are quite similar all over the world. If healthcare were an industrial sector, we would be trying to reach 6-SIGMA. Hundreds of industrial companies have already reached this level, with 3 to 4 defective products for every million products. In healthcare, up to XNUMX people die due to procedural errors. 6 for every thousand people admitted to hospital[efn_note]https://agenciabrasil.ebc.com.br/saude/noticia/2018-08/eventos-adversos-graves-matam-6-pessoas-cada-hora-no-brasil[/efn_note]. In other words, 6.000 people die in healthcare for every million, while in industry there are 4 errors per million. The difference is that industry is 1.500 times safer than healthcare.

In the aviation industry, a total of 257 people died in plane crashes in 2019. The number over the last 6 years is less than the 400 lives lost in air disasters. To equal this number of 400 deaths due to errors per year, in healthcare we only need one hospital with 915 beds, that is, a single hospital equals all aviation deaths.

Why that?

We are still not doing enough

Hospital procedures are, in many cases, at the beginning of the Quality implementation curve.

As an example we can mention the 5.000.000 deaths worldwide per year from hospital infections[efn_note]https://www.who.int/news-room/fact-sheets/detail/patient-safety[/efn_note]. The WHO launched the first global hand hygiene challenge in 2005. It was only 15 years ago that we had to educate the entire sector on the need to wash hands. As if Florence Nightingale[efn_note]https://pt.wikipedia.org/wiki/Florence_Nightingale[/efn_note] (1820-1910) had not left any clear message about the importance of hygiene 150 years ago.

We are at the beginning of a discipline of Quality and Patient Safety and we are still not doing enough.

Patient Safety is a discipline included in Quality, or Quality Assurance, both use many tools in common, but Safety studies Error, while Quality seeks the efficiency of results. For example, a patient may die due to delayed treatment for a heart attack, but this is not an error, it is a Quality problem.

Os Adverse events (EA) are considered “damaging errors”.

For an error to occur, we may have problems with processes, personnel, or management, and more than 95% of the time the error is in the system: process + technology and rarely in the solely human factor.

Communication failures, lack of information, lack of protocols and a series of other unsafe conditions in the system can lead to a lack of trust between professionals and patients, becoming high-risk conditions and revealing a lack of safety.

Near events (near misses in English) are incidents that were close to becoming a Adverse Event but they have not reached the end of the process and therefore are not an EA.

These near misses or accidents ready to happen represent an excellent opportunity to learn about the context of the potential error and thus prevent the error from happening.

Worldwide, AEs cause 4,8 MILLION[efn_note]https://donate.patientsafetymovement.org/campaign/givingtuesday/c253206[/efn_note] of death each year and are the third leading cause of death in the US, after cancer and cardiovascular problems.

When the Manifesto of the Institute of Medicine[efn_note]https://pubmed.ncbi.nlm.nih.gov/25077248/[/efn_note], 44.000 to 100.000 deaths were reported per year in the United States. This number is now estimated at 200.000 to 400.000 per year. This increase is due to better information and more self-reporting. And it is recognized that the problem of Quality is still far from being resolved, even though there are numerous organizations working on the issue.

– If we take the smallest number of AEs – 200.000 per year – and divide it by 33 million hospital admissions, it gives us a 6/1000 probability of deaths per hospital admission in the US.

– If we consider the 4,8 million deaths worldwide due to AE and divide this by 800 million hospital admissions, this also gives us 6/1000 deaths due to hospital admissions.

In Brazil, with 20 million hospitalizations[efn_note]https://www.iess.org.br/cms/rep/Anuario2018.pdf[/efn_note], would be 120.000 deaths per year due to AEs and also 6/1000 deaths due to hospitalization, although the number could be even higher and reach 300.000 deaths per year.

A study by Christiane Santiago Maia[efn_note]https://www.scielosp.org/pdf/ress/2018.v27n2/e2017320/pt[/efn_note], carried out in Brazil between 2014 and 2016, indicates a high variation in patient deaths due to AE in 2015, 104.000 to 434.000[efn_note]https://www.scielosp.org/pdf/ress/2018.v27n2/e2017320/pt[/efn_note]. Underreporting of AEs in Brazil directly affects the AE rate in the country.

The number of errors is higher in developing countries, where the possibility of scarce personnel and very long working hours, the lack of adequate communication, the lack of equipment and preventive measures in the processes, further increase the rates of AEs.

According to the II Yearbook of Hospital Care Safety in Brazil [efn_note]https://www.iess.org.br/cms/rep/Anuario2018.pdf[/efn_note] published in 2018, patients exposed to Adverse Events during hospital admissions in Brazil consumed an amount of bed-days that would allow the hospitalization of 2.923.717 more Brazilians, corresponding to a 15% increase in hospital admissions in Brazil.

If we relate this number to the 20 million Brazilians who are admitted to a hospital each year, it gives us approximately 15% of hospital care resources destined to treat AE, in accordance with OECD estimates.[efn_note]http://www.itamaraty.gov.br/pt-BR/politica-externa/diplomacia-economica-comercial-e-financeira/15584-o-brasil-e-a-ocde[/efn_note], which also shows that the costs of patient safety problems worldwide reach 15% of total expenses.

This confirms the value of 15% of wasted spending due to AE, which should draw the attention of hospital managers with regard to Quality.

– MEDICATION

According to WHO[efn_note]https://www.who.int/news-room/fact-sheets/detail/patient-safety[/efn_note] 10% of procedures have some adverse outcome which, according to other authors, can also vary between 8 and 14% depending on the country. In studies using Global Trigger Tool, DC Classes[efn_note]CLASSEN DC, Resar R, Griffin F, et AL. 'Global Trigger Tool' shows that adverse events in hospital may be longer than previously measured. Health Aff (Millwood) 2011; 30:581-589.[/efn_note] found 1 AE in every 3 admissions.

Dr. Robert Watcher[efn_note]WACHTER, RM Understanding Patient Safety. Porto Alegre: Artmed, 2010; 30-33.[/efn_note] writes that in 50% of these, 10% of AEs in admissions are avoidable, but that 1 in every 3 AEs causes real harm to the patient.

Error is when the result is not as expected and is different from the objective of that procedure.. Unavoidable incidents are contraindications of medications and other incidents that are likely to occur with these procedures and are not considered professional errors.

According to David W. Bates[efn_note]Bates DW. Incidence of adverse drug events and potential adverse drug events. JAMA.1995;274[1]:29-34[/efn_note], 30% of all hospital AEs occur in the Medication process, which includes: 1) Medical prescription, 2) Dispensing by the Pharmacy and 3) Administration of medications by the Nursing team.

Bibliographies present a variation between the main causes of AEs due to medications. Studies cite variations of 20%[efn_note]http://portal.anvisa.gov.br/documents/33868/2894786/Boletim+de+Farmacovigil%C3%A2ncia+n%C2%BA+08/a82130ea-7f22-4c41-af7c-d5047ad9891c[/efn_note] up to 40%[efn_note]https://www.saraiva.com.br/seguranca-do-paciente-5582236/p[/efn_note] of AEs caused by errors in medication administration that are related to medication reconciliation in the stages of patient admission, transfer and discharge. Of these, 20%[efn_note]https://www.saraiva.com.br/seguranca-do-paciente-5582236/p[/efn_note] result in harm to patients.

According to the pharmacovigilance bulletin[efn_note]http://portal.anvisa.gov.br/documents/33868/2894786/Boletim+de+Farmacovigilância+nº+08/a82130ea-7f22-4c41-af7c-d5047ad9891c[/efn_note] presented by ANVISA the most common errors are related to the dose, type or volume of diluent, omission of medications and incorrect hydration route.

In England, it is estimated that 237 million occur[efn_note]http://portal.anvisa.gov.br/documents/33868/2894786/Boletim+de+Farmacovigil%C3%A2ncia+n%C2%BA+08/a82130ea-7f22-4c41-af7c-d5047ad9891c[/efn_note] of medication errors annually. Of these, approximately 50% are administration errors, with minimal or no potential for clinical harm. This indicates 4 medication errors per admission, or approximately 1 medication error per day of stay.

In Brazil, studies carried out in all five regions of the country demonstrated that 30%[efn_note]http://portal.anvisa.gov.br/documents/33868/2894786/Boletim+de+Farmacovigil%C3%A2ncia+n%C2%BA+08/a82130ea-7f22-4c41-af7c-d5047ad9891c[/efn_note] of the doses administered contained some flaw.

Many countries suffer from quality and patient safety issues. The complexity of modern medicine increases the risk, with increasingly risky medications.

Faced with large numbers and problems, it is necessary to do everything possible to create processes and protocols capable of acting on these major risks.

The losses in lives and the economy are enormous.

– HOSPITAL INFECTIONS

The infections[efn_note]https://www.who.int/infection-prevention/en/[/efn_note] associated with health care occur in 10% of hospitalized patients.

It is estimated that 125.000 Brazilians die annually from hospital infections.

Infections can have several causes, such as lack of hand hygiene, lack of antisepsis technique, lack of technique during catheter insertion or change of catheter insertion site. Several reasons related to catheters can lead to infections.[efn_note]https://proqualis.net/sites/proqualis.net/files/000001477obt2No.pdf[/efn_note].

The different types of EA unfortunately allow us to present even sadder health figures:

Infections caused by sepsis[efn_note]https://www.who.int/news-room/fact-sheets/detail/sepsis[/efn_note] They are often not diagnosed early enough to save a patient's life and are often resistant to antibiotics, which can quickly lead to deterioration of patients' clinical conditions, affecting around 30 million people worldwide.

It is estimated that 3 million[efn_note]https://www.who.int/news-room/fact-sheets/detail/sepsis[/efn_note] of newborns and 1,2 million[efn_note]https://www.who.int/news-room/fact-sheets/detail/sepsis[/efn_note] of children suffer from sepsis each year in the world.

According to Global Guidelines for the Prevention of Surgical Site Infection[efn_note]https://apps.who.int/iris/bitstream/handle/10665/250680/9789241549882-eng.pdf?sequence=8[/efn_note] produced by the WHO, staphylococcal infections occur regularly in hospitalized patients and can occur in postoperative wounds, pneumonia, catheter-related bacteremia. The staphylococcus aureus can occur in 80%[efn_note]https://apps.who.int/iris/bitstream/handle/10665/250680/9789241549882-eng.pdf?sequence=8[/efn_note] of surgeries.

Given all this, preventing infections and training employees to reduce their risks is extremely important.

– PRESSURE INJURY

Unfortunately, pressure injuries are also high. Estimates in the US indicate that approximately 2,5 million[efn_note]https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/index.html[/efn_note] of patients per year will develop a pressure injury and that 60.000 patients per year die from complications related to these injuries.

In addition to the pain and discomfort caused by injuries, they are directly linked to the risk of serious infections. And they become more relevant depending on the critical condition of hospitalized patients. Therefore, it is important to invest in preventing injuries in patients.

There are pressure injury prevention training courses available from various healthcare institutions such as Agency for Healthcare Research and Quality (AHRQ[efn_note]https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/guide1.html[/efn_note]), WHO, ANVISA[efn_note]https://www20.anvisa.gov.br/segurancadopaciente/index.php/publicacoes/category/diversos[/efn_note].

– PATIENT FALL

Falls are widely reported in hospitals around the world. The highest rates are among the elderly.[efn_note]https://www20.anvisa.gov.br/segurancadopaciente/index.php/publicacoes/item/prevencao-de-quedas[/efn_note] and are associated with increased length of hospital stay for patients.

The percentages of falls vary greatly according to the hospital specialties, with the rates having a wide variation range from 1,4 to 13,0 falls / 1000 patient-days.[efn_note]OLIVER, et al, 2004; CORREA, et al, 2012; BRAZIL, 2013[/efn_note]. They often result in bruising, abrasions, bleeding and serious injuries, such as fractures that can lead to death.7. They also generate an increase of 6,3 days[efn_note]https://www.ahrq.gov/professionals/systems/hospital/fallpxtraining/workshop/module1/mod1-trguide.html[/efn_note] more hospitalization for patients and the average operating cost for a fall is about $14.200 in the US.

In order to reduce these AEs, there are contents such as classes, indicators, videos, readings, tools, protocols that are available.[efn_note]https://proqualis.net/preven%C3%A7%C3%A3o-de-quedas[/efn_note] for access by health institutions such as Agency for HealthCare Research and Quality (AHRQ[efn_note]https://www.ahrq.gov/professionals/systems/hospital/fallpxtraining/workshop/module1/mod1-trguide.html[/efn_note]), WHO and ANVISA[efn_note]https://www20.anvisa.gov.br/segurancadopaciente/index.php/publicacoes/category/diversos[/efn_note].

– FAILURES IN PATIENT IDENTIFICATION

Patient identification errors can occur from admission to discharge from the service, at all stages of patient diagnosis and treatment. Some factors such as lack of consciousness, change of bed, sector or professionals within the institution, as well as other circumstances in the environment can increase the risks in patient identification.

In every 1.000 patients who receive blood or blood component transfusions, one individual receives one intended for another person, that is, 1/1000, and in two thirds of cases, the reason is incorrect identification of the bag.

The implementation of patient identification processes produces significant reductions in the occurrence of errors related to patient identification and for this to happen, a lot of training is necessary so that teams understand the need to comply with protocols.[efn_note]https://www20.anvisa.gov.br/segurancadopaciente/index.php/publicacoes/item/identificacao-do-paciente[/efn_note].

– UNSAFE TRANSFUSION AND INJECTION PRACTICES

They expose patients to the risk of adverse reactions to transfusion and transmission of infections. Data on adverse reactions[efn_note]https://www.who.int/news-room/fact-sheets/detail/patient-safety[/efn_note] transfusion data from a group of 21 countries show an average incidence of 8,7 serious reactions per 100.000 blood components distributed.

For injections, it is possible to cite the Guidelines Guide[efn_note]https://apps.who.int/iris/bitstream/handle/10665/250144/9789241549820-eng.pdf?sequence=1[/efn_note] of safety guidelines for injections published by the WHO.

It states that injections are one of the most common procedures in healthcare and that approximately 16 billion injections are administered each year worldwide.

Injections cause long-term harm, causing an estimated 9,2 million years of life lost (DALYs) through disability and death worldwide.

Needlestick injuries lead to the transmission of various diseases and infections. Also according to the WHO, 40% of these 16 billion injections were administered with reusable injection equipment, leading to 21 million new cases of Hepatitis B, 2 million new cases of HCV Hepatitis C and about 260.000 new cases of HIV.

DIAGNOSTIC ERRORS

In the US it is estimated that there are more than 12 million[efn_note]https://www.iess.org.br/cms/rep/Anuario2018.pdf[/efn_note] of patients per year experience an outpatient diagnostic error, and 50% of these diagnostic errors have the potential to cause harm. Most people will experience a diagnostic error[efn_note]https://www.who.int/news-room/fact-sheets/detail/patient-safety[/efn_note] in life.

VENOUS THROMBOEMBOLISM

Venous thromboembolism[efn_note]https://www.who.int/news-room/fact-sheets/detail/patient-safety[/efn_note] It is one of the most common and preventable causes of patient harm, contributing to one-third of complications attributed to hospitalization. Annually, it is estimated that 3,9 million cases occur in high-income countries and 6 million cases in low- and middle-income countries.

SAFE SURGERY

Surgical care[efn_note]http://bvsms.saude.gov.br/bvs/publicacoes/seguranca_paciente_cirurgias_seguras_guia.pdf[/efn_note] are an integral part of health care. There are an estimated 234 million[efn_note]http://bvsms.saude.gov.br/bvs/publicacoes/seguranca_paciente_cirurgias_seguras_guia.pdf[/efn_note] surgeries per year. Although surgery can prevent loss of life, it is also associated with a considerable risk of complications and death. The risk of death from in-hospital surgery ranges from 0,4% to 0,8%, and the complication rate from surgery ranges from 3% to 30%.[efn_note]http://bvsms.saude.gov.br/bvs/publicacoes/seguranca_paciente_cirurgias_seguras_guia.pdf[/efn_note].

Wrong-site, wrong-patient surgeries are estimated to occur in about 1 in every 50.000 to 100.000[efn_note]https://proqualis.net/indicadores/n%C3%BAmero-de-cirurgias-realizadas-no-paciente-errado[/efn_note] procedures in the US, equivalent to 1.500 to 2.500[efn_note]https://proqualis.net/indicadores/n%C3%BAmero-de-cirurgias-realizadas-no-paciente-errado[/efn_note] adverse events of this type per year.

Unsafe surgical care procedures[efn_note]http://bvsms.saude.gov.br/bvs/publicacoes/seguranca_paciente_cirurgias_seguras_guia.pdf[/efn_note] cause complications in up to 25% of patients.

In 2008, the WHO published guidelines with recommendations to ensure the safety of surgical patients and reduce the risks of surgery. Safe surgery checklist[efn_note]http://bvsms.saude.gov.br/bvs/publicacoes/seguranca_paciente_cirurgias_seguras_guia.pdf[/efn_note] where they will be checked by members of the surgical team before anesthesia, patient's name, which surgery, location of surgery, patient's pulse, airway and risks of aspiration of the patient, if there is a risk of bleeding, if the patient has any allergies to medications and the names and roles of team members.

To address the challenges of insecurity and quality deviations, according to WHO, 140 countries[efn_note]https://www.who.int/features/factfiles/patient_safety/patient_safety_facts/en/index9.html[/efn_note] in the world work with a focus on safe care.

Despite the search for improvements, the annual report on the Quality of National Health AHRQ[efn_note]https://www.ahrq.gov/patient-safety/resources/advances/index.html[/efn_note] continues to point to the need for safer care as a top priority. He reports that quality and access to health care remain suboptimal and for minorities and low-income groups, the rate of improvement is only 2,5% per year.

This requires profound changes, there must be commitment from both the individuals working in health and the organizations in which they work:

– It is necessary to know the size of the problem and have a clear commitment to redesigning the system to achieve important levels of security.

– It is necessary to recognize the importance of integrated teamwork with patients and family members to improve safety.

The foundation has been in place for seven years Patient Safety Movement[efn_note]https://www.fiercehealthcare.com/hospitals-health-systems/two-decades-after-landmark-iom-report-group-still-fighting-to-convince[/efn_note] launched an audacious goal of achieving zero preventable patient deaths by 2020.

They have released a collection of free tools for patients and hospitals to improve safety and prevent preventable patient deaths. Despite numerous attempts, the problem will not improve until organizations are brave enough to openly address the problem and, in a transparent manner, are more willing and confident in the need to invest in solutions to eliminate the sources from which errors that can interfere with patient safety arise.

In an environment where there are high-risk medications, healthcare conflicts, quick decisions and frequent distractions, it is necessary to use automated or computerized systems to conduct the processes, but always with the close and continuous supervision and surveillance of healthcare professionals, after all, redundancy is essential to guarantee safety.

ABSTRACT

It is necessary to create methodologies related to patient safety, always offer continuing education and training in matters related to quality, customer service, ethics, interactivity, better results, customer and employee satisfaction. Invest in the ability to learn and the desire to be and do the best.

Alignments to follow:

  • We are not doing enough yet. We have to do more.
  • Procedure, training, procedure, training.
  • Polishing procedures and training is the first topic.
  • Use barcodes in all links in the process chain.
  • Use Checklist in full.
  • Increase the use of computer technology.
  • Being redundant with information.
  • Participate in hospital accreditation.
  • Have a Quality and Patient Safety sector.
  • Allow adequate time for each procedure.
  • Create a culture of improvement and avoid a culture of blame.
  • Not every issue in the hospital should be confidential. We need more transparency.

Victor Basso
director of Opuspac Ltda.
Opuspac University (corporate university – educational arm of Opuspac Ltd)

Daniela Faria – Pharmacist CRF/SP 51.617
Patient Safety Manager – Opuspac Ltda

REFERENCES