Dear HIFA colleagues,
Below are some highlights from our discussion relating to Q2. What are the main causes of unsafe care for people living with NCDs? To what extent is access to reliable healthcare information a determinant of patient safety?
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"We now have a good understanding of how harm occurs. However many health systems still struggle to provide safe, coordinated, and reliable care for conditions such as diabetes, hypertension, cardiovascular disease, chronic respiratory disease, and cancer. These challenges affect millions of people every day, especially those in low-resource settings."
“Major causes include late diagnosis, inadequate screening, medicine stock-outs, polypharmacy, poor continuity of care, weak referral systems, limited diagnostic capacity, insufficiently trained health workers, overcrowded facilities and poor patient-provider communication.” (Note that a few of these such as late diagnosis are consequences of unsafe care.)
“Unsafe NCD care emerges from systemic gaps in primary care, information access, coordination, training, supply chains, equity, and governance.”
"In our setting [rural Dominican Republic], the most common form of unsafe NCD care is not a dramatic clinical error. It is a quiet failure of continuity."
"Often, when people think of critical illness, they assume these patients are in ICUs, and as there are only a few ICU beds, it appears to be a minor issue. But ACIOS [African Critical Illness Outcomes Study] found that one in eight inpatients are critically ill and less than half of them receive essential emergency and critical care."
"Rather than being the main instigators of an accident, operators tend to be the inheritors of system defects created by poor design, incorrect installation, faulty maintenance and bad management decisions. Their part is usually that of adding the final garnish to a lethal brew whose ingredients have already been long in the cooking."
"People of course play a part when things go wrong, but they are simply the final link in the chain, the final garnish to a lethal brew as Jim Reason memorably says. Clinical staff are often 'set up to fail' by the systems they work in, as the story of the missed diagnosis [epiglottitis] showed us."
"First, there was fragmentation. Different symptoms were considered separately, there was apparently no one putting them together, and when initial treatments did not help, there was not always effective follow-up or reassessment. Several symptoms were attributed to pre-existing problems or ageing rather than prompting a broader review. The eventual delay in diagnosis resulted in significant and lasting harm."
"Second, there was the “everyone is a doctor” problem. Family members and other non-medical people were understandably trying to help, but were making medical suggestions that influenced the patient's decisions."
"The risk we saw [in Eritrea] most often wasn't a single dramatic error, it was accumulation. Someone managing two or three conditions at once, on multiple medications, with limited health literacy and no one coordinating the whole picture. A missed follow-up or a misunderstood dosage rarely looked dramatic in the moment, but it compounded over months."
TO WHAT EXTENT IS ACCESS TO RELIABLE HEALTHCARE INFORMATION A DETERMINANT OF PATIENT SAFETY?
“One of the main causes of ‘unsafe care’ for people living with NCDs is ‘lack of access to reliable healthcare information’ for both patients and healthcare providers.”
“Patients may not be aware of evidence-based scientific knowledge on prevention, early detection, and appropriate, timely treatment.”
“Health providers at the primary and community level often lack access to scientific updates to guide and communicate to patients on early detection, diagnoses, and to make treatment and follow-up decisions.”
“Lack of updated evidence-based standard protocols at health facilities for treatment and for avoiding medication, diagnostic, and equipment errors is also one of the causes of ‘unsafe care’.”
“Reliable health information is a fundamental determinant of safety.”
“Reliable information sits at the center of this.”
“When that information is fragmented, safe management of a chronic disease becomes almost impossible, however skilled the individual clinician.”
“Failure to translate evidence into policy and practice is a glaring cause of poor-quality and unsafe care.”
"The [Global Patient Safety Action] plan does not acknowledge lack of availability of reliable healthcare informationas a patient safety issue. This seems to be a major gap in the plan."
Best wishes, Neil
HIFA profile: Neil Pakenham-Walsh is coordinator of HIFA (Healthcare Information For All), a global health community that brings all stakeholders together around the shared goal of universal access to reliable healthcare information. HIFA has 20,000 members in 180 countries, interacting in four languages and representing all parts of the global evidence ecosystem. HIFA is administered by Global Healthcare Information Network, a UK-based nonprofit in official relations with the World Health Organization. Email: neil@hifa.org