At the most recent CSRT conference, I attended a talk by Brian Walsh (President of the American Association of Respiratory Care) entitled “The Professional Road Ahead”. The purpose of Brian’s presentation was to look at some of the ways that RTs have the potential to make a significant impact – not just in the lives of their individual patients, but on the healthcare system as a whole. And one of the areas of substantial influence he identified was in the reduction of fatal medical errors. Brian cited a recent study published in the British Medical Journal, which stated that the top three leading causes of death in the U.S are:
- Heart disease
- Medical Errors[i]
Canada isn’t likely very far behind. Accurate data on deaths caused medical error in this country is sorely lacking, but we do know that approximately one in every eight patients admitted to a Canadian hospital suffers some type of harmful event that ends in death.[ii] This despite an enhanced emphasis on safety (most hospitals now have Patient Safety Committees) and focused safety initiatives that some organizations like Sick Kids have undertaken.[iii]
Fortunately, most patients experience safe care and even when adverse events do happen, evidence shows errors are rarely the fault of one person, but rather a confluence of events. This means that there are a lot of large-scale, system-wide changes that need to take place in order to shift one in eight to closer let’s say 0.25 in eight (it will likely never be zero); such as accurate province-wide reporting and tracking of deaths caused by medical errors. And we still have a way to go in creating a culture that encourages healthcare providers to disclose and apologize for mistakes made without fear of reprisal.
So, what can an individual RT do to tackle such a complex problem as fatal medical errors? Well, the high-acuity nature of RT work makes us ideally positioned to identify error-prone situations that place patients at the greatest risk of a preventable adverse outcome. According a 2008 article in Critical Care, “Critically ill patients are prescribed twice as many medications as patients outside of the intensive care unit (ICU) and nearly all will suffer a potentially life-threatening error at some point during their stay.[iv] In his presentation, Brian Walsh also referred to an article posted in the Boston Globe in 2011 called “Ventilator Errors Associated with 119 Nationwide Deaths from 2005 – 2001”.[v] The cause of these ventilator-associated deaths were varied and included such things as improperly set alarms and alarms that were silenced without any corresponding corrective action (sometimes the result of what is referred to as “alarm fatigue”). Alarms tops the list of the most hazardous health technology and, thus RTs have a significant opportunity to lead initiatives aimed at ensuring ventilator alarms are set, recognized and responded to appropriately.[vi]
We need to speak up loud and clear to the appropriate entity when we observe a human, technical or organization process failure that puts patients at risk. I must admit that I receive quite a few emails from RTs trying to find out how much assistance the CRTO can provide with a variety of patient safety issues – usually regarding workload issues. And the answer to how much assistance the CRTO can provide is – usually not much – because we do not have any jurisdiction over the RT’s employer. But RTs do have the ability to influence change in their respective organizations. There is undoubtedly someone or a group of someones at each facility that exists to manage issues that puts patients (and the organization) at risk, such as Quality & Risk Management Departments. On a daily basis, most RTs witness potential patient safety risks that many others simply may not see, and so it up to us to bring those issues forward and help develop innovative solutions. The opportunity for each individual RTs to have a positive impact on the very serious problem of fatal medical errors is tremendous, and one we (or our patients) simply cannot afford to miss.
[i] Makary, M. A & Daniel, M. (2016). Medical error: The third leading cause of death in the US. British Medical Journal. 353:i2139. Retrieved from http://www.bmj.com/content/353/bmj.i2139
[ii] Canadian Institute for Health Information. (2016). Measuring patient Harm in Canadian hospitals. Retrieved from http://www.patientsafetyinstitute.ca/en/toolsResources/Hospital-Harm-Measure/Documents/CIHI%20CPSI%20Hospital%20Harm%20Report%20EN.pdf
[iii] Weeks, C. (2016, June 26). How hospitals are seeking to prevent medical error deaths. The Globe and Mail. Retrieved from https://www.theglobeandmail.com/life/health-and-fitness/health/toronto-hospitals-embark-on-safety-initiative-to-prevent-medical-error-deaths/article30610569/
[iv] Moyen, E., Camiré, E., & Stelfox, H. T. (2008). Clinical review: Medication errors in critical care. Critical Care, 12(2), 208. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2447555/
[v] Oh, J. (2011, December 12). Ventilator errors associated with 119 nationwide deaths from 2005-2011. Boston Globe. Retrieved from http://www.beckersasc.com/asc-quality-infection-control/ventilator-errors-associated-with-119-nationwide-deaths-from-2005-2011.html
[vi] ECRI Institute. (2014). ECRI Institute announces top 10 health technology hazards for 2015. Retrieved from https://www.ecri.org/press/Pages/ECRI-Institute-Announces-Top-10-Health-Technology-Hazards-for-2015.aspx