At the recent CSRT conference, I had the pleasure of listening to Brent Kitchen an RRT from Saskatchewan speak about “Using Mistake Proofing to Prevent Harm”.  In his presentation, he referenced the Canadian Adverse Events Study, which found that approximately 7.5% of adult hospital admissions involve an adverse event “resulting in death, disability or prolonged hospital stay”[i].  The actual percentage is likely much higher because the study did not involve all provinces and did not include paediatric patients or adult patients in long-term care facilities.  The World Health Organization (WHO) puts the risk of being harmed in the healthcare system at 1 in 300, significantly greater than the risk of being hurt flying in a plane (1 in 1,000,000)[ii].  The WHO’s statistics are impacted by the number of incidences that occur in the healthcare systems of developing countries, which may be higher than in Canada.  Nevertheless, it is estimated that adverse events in this country result in approximately 2 – 4 needless deaths per day.

Many adverse events result from preventable medication and surgical errors caused by poor communication (both verbal and written) and inadequate infection control practices.  Research conducted in Canada and the U.S. indicates that the financial and human cost associated with these incidents can be alleviated through careful application of evidence-based medicine.  For example, healthcare-associated infections – such as catheter-associated bloodstream infections (CABSI) and ventilator- associated pneumonias (VAP) – are a major source of adverse events[iii].  Fortunately, numerous studies demonstrate that well over half of infections like CABSI and VAP can be avoided through evidence-based infection prevention and control practices.

That being said, there is sometimes a tendency to think that safety is someone else’s job; that managers and infection control practitioners (some of whom are Respiratory Therapists), should establish and ensure compliance with current best-practices. However, all Respiratory Therapists play a very important role in reducing the frequency and severity of adverse events.  Our specialized knowledge and perspective offers a unique opportunity to identify situations when the appropriate level of evidence-based care is not being provided (e.g., improper use of PPE).  We are often the ideal profession to take the lead in collaborative initiatives, aimed at reducing preventable adverse events and improving patient care outcomes.




[i] Baker, G. N., Baker, G. R., Norton, P. G., Flintoft, V., Blais, R., Brown, A., . . . Tamblyn, R. (2004). The Canadian adverse events study: The incidence of adverse events among hospital patients in Canada. Canadian Medical Association Journal, 170(11), 1678-1686.  doi: 10.1503/cmaj.1040498

[ii] Boinot, P. (2009, October 19). Preventable adverse events in healthcare: Issues and solutions [Blog post]. Retrieved from http://www.hinnovic.org/preventable-adverse-events-in-healthcare-issues-and-solutions/

[iii] Umscheid, C. A., Mitchell, M. D., Doshi, J. A., Rajender, A., Williams, K., & Brennan, P. J. (2011). Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infection Control and Hospital Epidemiology, 32(2), 101-114. doi: 10.1086/657912

COMMENTS | The RT role in Enhancing Patient Safety

  1. Great post! You are so right, all respiratory therapists and all healthcare professionals are responsibile for patient safety. Everyone, including the leadership team, needs to work together to keep our patients safe and work towards a safe culture.

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