Patient safety concerns lacking, study finds

Community Action, June 14, 2004

OTTAWA -- Limited financial and human resources pins the lack of leadership on local, regional and national levels adversely affects the ability of health organizations to deal with patient safety concerns in Canada says a report on patient safety in Canadian health institutions.

Almost 50 per cent of organizations that currently deliver healthcare say they could not effectively enhance patient safety according to the report, Patient Safety and Healthcare Error in the Canadian Healthcare System.

The report is based on a literature review, telephone and mail surveys of individuals who currently work on patient safety in Canada and an "analysis of the gaps between current safety practices of the Canadian organizations, programs and individuals and studies elsewhere."

The report indicates that the fear of litigation which was thought to be significant was not as important in many organizations as anticipated. However, punishment, fear and possible professional censure are "major barriers to identifying and investigating adverse events at the local level."

Further, few co-ordinated and systematic processes to collect information on adverse events and errors in Canadian healthcare organizations exist. Historical surveillance systems for tracking errors, such as death reviews and incident analysis, were not functioning well or were not present at all.

Respondents to the surveys identified a need for education among healthcare professionals concerning safety patient issues with many saying that "we need to go upstream" by focussing on systems of prevention of error.

Among the recommendations included in the report are:

* a call for governments and other stakeholders to convene an expert committee representing clinical disciplines and management with knowledge of patient safety systems, tools and other resources to develop an agenda for addressing patient safety in Canadian healthcare.

* an invitational meeting be convened for senior leaders in healthcare to build awareness of "the roles of leaders in creating organizational cultures that support patient safety."

* testing new regional and national reporting systems and mechanisms through pilot projects along with expanded support for the existing Adverse Drug Event system.

* Integration of patient safety programs into healthcare accreditation standards along with legislative change to enhance reporting or errors and near-misses.

The study was funded by Health Canada.