To the credit of the Airline industry, they seemed to figure it out, 40 years ago. The development of the Aviation Safety Reporting System (ASRS) to allow pilots to report near misses without the ramification of potential firing was a brilliant idea, one that should be modeled by other large organizations/fields. It is beyond my belief that such a sophisticated field such as medicine with it's wealth of highly, highly educated individuals at all levels would not have figured this problem out. Why has there not been the development of a third independent party that would catalogue and share potential problems/solutions for doctors, nurses and the field of medicine as a whole? Think of the potential cost savings both financial and in lives. It is utterly tragic that people continue to die as a result of the blame and shame culture that Vicente writes about. It is horrific that society as a whole does not demand change for the sake of tax payers dollars and lives.
What is happening here in Alberta?
I did some research to see what type of reporting measures we have here in Alberta within the field of medicine. It turns out that the Alberta government recently established a framework for patient safety called the "Patient Safety Framework for Alberta" in September of 2010
The Patient Safety Framework contains 5 key principles which include:
- Patients are the primary focus,
- Organizations create a patient safety culture,
- Information about adverse events is shared in a transparent manner,
- A systems approach is required to understand and address the complexity of factors that contribute to error
- A continuous improvement approach strengthens an organization's ability to use new knowledge to make informed patient safety improvements.
It was very exciting to see that there was an acknowledgement of the systems role in harming patients. "Errors are viewed as one factor contributing to patient harms but many other factors in the system also play a role" (Health Quality Council of Alberta, 2010, p.6) How does this framework measure up to the principles that Vicente's writes about on the formation of ASRS? Is reporting of problems voluntary, confidential, non punitive and to an independent body within this framework?
This particular document highlights 6 strategies for the framework:
- Implement a Provincial Adverse Event Reporting and Learning System
- the details of this system are not included in the document and thus can not be evaluated with regards to the reporting process
- It is my hope that they are able to make the reporting voluntary and confidential and that this system is an independent body to whom reports are filed.
- Establish a Provincial Patient Safety Network
- Here is where the experts get involved. This is similar to what Charles Billings created within the ASRS. He had former pilots and experts in the field evaluate and catalogue the reports. The province has something similar in mind as well.
- Implement a Model of Safety Management
- Organizations will develop an implement operational policies on a just and trusting culture, reporting and learning from adverse events, informing and disclosure
- Appears to attempt to get away from the blame and shame culture. This appears to be essential to ensuring that reporting actually will happen. That the culture of medicine get away from burying mistakes and begin a dialogue to talk about them.
- Build knowledge and Capacity to support patient safety
- Implement a patient/ family Safety Advisory Panel
References
CTV.ca (September 20, 2010). Making it Easier to Report Medical Errors. CTV Calgary. Retrievied from http://calgary.ctv.ca/servlet/an/local/CTVNews/20100920/CGY_patient_error100920/20100920/?hub=CalgaryHome
Health Quality Council of Alberta. (September 2010). Patient Safety Framework for Albertans. Retrieved from http://www.hqca.ca/assets/pdf/Sept20/HQCA%20Patient%20Safety%20Framework%20081010.pdf
Health Quality Council of Alberta. (September 2010). Patient Safety Framework for Albertans. Retrieved from http://www.hqca.ca/assets/pdf/Sept20/HQCA%20Patient%20Safety%20Framework%20081010.pdf
Vicente, Kim J. (2004). The Human Factor: Revolutionizing the Way We Live with Technology. Toronto: Vintage Canada
Hi Kenzie,
ReplyDeleteInteresting post - I actually wrote about much the same topic and may be able to answer some of your questions. My sister recently changed jobs within AHS and is now responsible for analyzing data within the Patient Safety Framework that you discuss. She sent me a number of 'inside documents' that outline the processes involved in the Approach that I'd be happy to share ... if you are interested (but I know that the reading piles up! There is also a graphic outlining the process on my blog). It is reassuring to note that the process is voluntary and confidential. In the earlier analysis stages, reports are not anonymous to allow analysts to gather further information and to provide feedback to the reporter. In the later stages of the process names are 'scrubbed' and information becomes anonymous. I was also interested to note that reporters have the choice of sending a copy of the report to their supervisors, or not. My sister tells me that in 95% of reports submitted thus far reporters have chosen to send copies to their supervisors - I think that this really says something about the comfort that reporters have with the process.
Another interesting aspect of this process is that in the future there are plans to open up reporting to the public - i.e. in order to submit a report you would not have to be an AHS employee. I think that this also a move in the right direction.
I echo your thoughts in hoping that this process will alleviate the 'blame and shame' system that has dominated in health care. The Patient Safety Framework is in the 'roll-out' stage at this time. It will be interesting to see how the full implementation develops.
Finally, why do you think the airline industry is so far ahead of health care? Is it that health care is in the business of dealing with individuals? I suppose when an individual 'goes down' there isn't the same reaction as when an airplane goes down - possible containing hundreds of individuals ... something to think about.
Thanks for an interesting read,
Robin