Oleh : Thomas Behrenbeck, MD (Cardiologist, Mayo Clinic, USA) Dipresentasikan pada Forum Mutu Pelayanan Kesehatan IHQN (Jakarta 19-20 November 2013)

“Our [medical] systems are too complex to expect merely extraordinary people to perform perfectly
100% of the time. It is our responsibility to put in place systems to support safe practice.”
Modified from James Conway, COO Dana-Farber Cancer Center

Quality and safety are inextricably linked in the delivery of health care when it aspires to provide the best care for the patient. A large part of this conference is dedicated to the improvement of health care in the new era of Universal Health Care coverage, this presentation will focus on the safety aspect as it pertains to quality.

The landmark report “To err is human” in 1999 by Kohn et al, pointed out that about 44,000 Americans by conservative estimate, and 98,000 by other studies die every year as a result of medical error. Despite these significant numbers, there is still reluctance in medical systems to openly discuss medical errors. Partly, this is due to the approach that an institution takes towards errors, especially when they cause irreparable harm: ‘Who made the error’, whereas the correct question should have been: ‘What happened’. This approach will open the door to the most rewarding discussion: ‘How can we learn from this experience?’, ‘How can we prevent a similar incidence like this in the future’. The key to success is to avoid seeking to place blame, since nobody conscientiously wants to cause harm, but to ensure that we understand the processes leading to the adverse event better and to create a support system which abolishes such problems.

It is now understood that about 80% of medical errors are system based. To take a more detached view, a stochastic approach might be most beneficial. Medical care is a sequence of complicated, interconnected steps, each of them carrying an inherent chance for error. In a simplified model, where each step carries a failure rate of 1 in 1000 times this step is performed, the chances that a multistep process is executed without error can easily be calculated. In a procedure including 25 steps, the probability of success is 78%, when 50 steps are necessary, it drops to 61%, and in a complicated sequence requiring 100 steps, the chance for success drops to less than half, 37%!
From this, some of the most important tenets for maximizing patient safety become apparent: Procedures should be analyzed in accordance to their complexity. It may be safer to break a procedure down into fewer steps, and have checkpoints along the way; ensure that every checkpoint is met before proceeding to the next level. System changes will increase the likelihood of success at every step, removal of unnecessary steps is critical to ensure increased patient safety.

Adverse events can take many forms. It can be due to delayed diagnoses, missed diagnoses, mistakes during treatment, medication errors, delayed reporting of results, miscommunication at any level, particularly though during transfers or transitions of care, inadequate postoperative care, and mistaken identity, not only to person, but also to site of surgery, confusion regarding left vs. right, etc.

The intersection of safety with quality is at the heart of the concept of reliability. Reliability is defined as patients getting the intended tests, medications, patient information, and procedures at the appropriate time and in accordance with patients’ values and preferences (IHI 2004). Since medicine is at its heart an all-or-nothing phenomenon, it is helpful to compare systems in other high risk industries, i.e., commercial flight, nuclear power industry, and even Formula 1 racing.

Safety as a priority in patient care requires cultural change, which is one of the most difficult to successfully achieve in any system. It is imperative that leadership in any medical institution wholeheartedly embrace the culture of safety, to foster an environment in which errors are looked upon as an opportunity to improve without the stigma of personal blame. Every participant in the health care process is a stakeholder in this critical process. Systems and procedures need to be analyzed on a cyclical basis to identify where best practice patterns need to be updated and simplified processes can be implemented to achieve optimal patient outcomes.

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