Red Cross Children’s Hospital
I graduated from Wits Medical School 40 years ago and completed my paediatric training at the Red Cross Children’s hospital and at UCT. As I celebrate the anniversary of my graduation I would also like to reflect on what I knew then about patient safety as opposed to what we know now.
In medical school, safety was assumed to be part of the role of being a professional. We swore to honour the Hippocratic Oath, without knowing how we were going to keep to the First do no Harm part of it. In medical school, though we had excellent clinical teaching, we were not taught about systems theory, human factors, patient safety or person-centred care. By inference, we learnt about the political system and how the larger macro system was a determinant of healthcare. Keeping patients safe was assumed, not taught. (Unfortunately, this has not changed to the degree it should).
My first experience of serious harm was when I was in my early days as a registrar at Red Cross Children’s Hospital. While on call one day, a house officer inadvertently gave a dose of KCl (potassium chloride) rather than NaCl (sodium chloride) to a baby with acute diarrheal disease, causing a cardiac arrest and the unfortunate death of the baby. The doctor and nurse were charged with manslaughter and, as I recall, did not return to work. There was no root cause analysis of the factors that caused this tragedy. There was no support for the family or the nurse and doctor. There was little understanding of the human factors that caused the failure of care, the design of the system or the folly of keeping the vials of KCl and NaCl side by side.
Paradoxically, we did have many elements of patient safety such as standardisation of care via the renowned Red Book, a Lean process in how we processed the patients with diarrhoea, and a respected and excellent clinical teaching programme. In essence at the Red Cross Hospital and UCT, we were already applying quality improvement methodology and patient safety theories without really knowing we were doing it; the field of patient safety was in its infancy and we did not have a science of patient safety or the concepts of Improvement Science to guide us.
Over the past 20 years, there have been major advances in the knowledge base and understanding of patient safety. We now have theories of quality and safety and understand the primacy of person-centred care. We understand the primacy of Human Factors, resilience and reliability theories. We know that systems theory is essential to design safe care. Yet this is still seen as the pastime of the few. Patient safety theories are not taught as an integrated part of the medical school curriculum. Human Factors theory and its application, systems theory and its importance, and resilience and teamwork are not the foundation on which the clinical subjects rest. This is a deficit that needs to be addressed.
And then there is the difficulty in implementation. The call for high quality, safe, equitable and person-centred universal health coverage is a challenge. We know “What” we need to do, “Why” we need to improve but the “How” is the challenge. We need to reflect and consider why it is so difficult to make the changes required to deliver safe, equitable person-centred care. Over the past 20 years, we have learnt that healthcare can be safer, and we have the technology that will help. But the culture needs to change. This means we need to review the way we interact with each other, how we place people in the centre of care and how we make safety the core business of healthcare.
The 17th September will be the first WHO Patient Safety Day which is a time to affirm our commitment to change and to keep people safe. And on 20th – 23rd October 2019 we will hold the annual ISQua conference in Cape Town, the first time it has been held in Africa. This will be an opportunity for us to discuss the latest theories and methods of being person-centred, safe and equitable.
I joined ISQua as the Chief Executive Officer in 2016. The International Society for Quality in Health Care (ISQua) is a member-based, not-for-profit community that delivers a variety of initiatives and programmes. Our mission is to inspire and empower people to advocate for and facilitate improvements in the quality and safety of healthcare worldwide.
At ISQua we believe we need to facilitate Knowledge, develop Networks, and give people a Voice. We offer Community Membership, a range of Education Programmes, External Evaluation services, Communities of Practice, and a number of regional and international Events and Conferences.
ISQua’s 36th International Conference, in partnership with the Council for Health Service Accreditation of South Africa (COHSASA) and Mediclinic International, will take place in Cape Town, South Africa, from 20th to 23rd October 2019. The theme for this year’s conference is ‘Innovate, Implement, Improve: Beating the Drum for Safety, Quality & Equity’.
I invite you to attend as it will be a chance to hear from experts from around the globe, but more importantly from those in Africa, who can demonstrate the progress that has been made. It is an opportunity for us to learn from each other and to see what can be done if we really try to make a difference. I would like to think that my first experience of a patient being harmed, which inspired me to look for answers, will help you think about the future of safe care.
For more details go to www.isqua.org