Health facilities are a place of healing and restoration. But can they be places of harm as well? The world over, one in 10 patients experiences or is subject to harm in health-care settings. These range from operations done on the wrong patient, to injections being administered in an unsafe manner. Studies in India have shown that more than two-thirds of injections are given in an unsafe manner; equally worrying is the fact that over two-thirds of injections in primary care are unnecessary in the first place.
Global focus
To highlight this important issue, the World Health Organization observes World Patient Safety Day every year (September 17). The theme for 2020 was ‘Health Worker Safety: A Priority for Patient Safety’ with a call to action to ‘Speak up for health worker safety!’ But one may wonder, why, on a day dedicated for patient safety, we should speak up for health worker safety? So, why is health worker safety important for patient safety?
Editorial | Protection for protectors: On safety of healthcare workers
Much harm done to patients in health-care settings is because of unsafe health-care practice and unsafe health-care communication. Unsafe health-care practice refers to unsafe or unnecessary procedures, wrong medications, medications given in a wrong dosage, etc. Unsafe health-care communication refers to mistakes made in health-care settings due to miscommunication between health professionals, for example, during patient handover in between staff shifts. The quality of both practice and communication is dependent on the safety and well-being of health workers. For example, numerous studies have shown that health workers, such as residents, who have been on duty for more than 24 hours at a stretch, have a higher risk of making mistakes, increasing the likelihood of a direct impact on patient safety.
COVID-19 and reporting cases
During the current COVID-19 crisis, health workers are not only putting in longer hours but also working under increasingly difficult circumstances, which affect both their physical and mental health. The mental health of health workers is linked to the workplace culture. Some organisations have a culture of supporting staff, responding to their needs and encouraging learning from mistakes; while others have a culture of fault-finding, blame, guilt and abuse. When instances of patient harm occur, whether people feel encouraged to report them, depends on the organisation’s culture and leadership.
Without reporting, it is difficult for organisations to learn from mistakes and create systems, such as check lists in order to prevent similar future occurrences. In addition, in India, it is not uncommon to find health-care organisations observe strict hierarchies between specialties, between designations, and between doctors and other health professionals, such as nurses. Such power differences can further prevent reporting and cooperative organisational learning and may, in fact, increase chances of abuse: verbal, physical, emotional and sexual, putting the safety of health workers and patients at risk.
Also read | In Chennai, doctor’s burial marred by protests, attacks
Looking at the organisation
Organisational learning is more important than individual learning. This is because instances of patient harm, even when they occur at the individual level, are often an end result of a chain of organisational failures.
For example, systemic under staffing, lack of reporting mechanisms, lack of dedicated time for hand overs, audits, training and team building, poorly maintained equipment and corruption in purchases, are all organisational failures that could result in a cascade leading to avoidable harm to the patient. Moreover, good systems can mitigate the effects of individual mistakes.
Thus, it is pertinent to look beyond the individual to look at the organisation as the sum of multiple elements that interact with each other. This involves taking a systems approach. What does that involve? Let us take the example of overcrowding. In many hospitals, quality of care is often compromised because of overcrowding, such as in the emergency department. To take a systems approach in this situation would mean looking at it holistically — for example, from at least three angles using the input-throughput-output conceptual model described by Asplin et al in the Annals of Emergency Medicine in 2003.
Editorial | Do no harm: on safety of health care workers
One, the input: looking at whether patients who come to the emergency department need to be there in the first place or could be managed somewhere else such as in the community itself. Two, the throughput: looking at whether there are inefficiencies such as shortage of doctors, nurses, equipment or space that is increasing the time taken for patients to be treated. And three, the output: looking at whether the patients are staying longer in the emergency department than required because of lack of non-emergency department inpatient beds, delays at the pharmacy or delays in transportation of patients out of the emergency department.
The conversation on health during COVID-19 has often centred on individuals, with certain individuals, such as health-care workers, seen as heroes, and others (including those referred to as ‘super spreaders’ in a stigmatising way), seen as villains. Many health workers have demonstrated excellence despite the limitations in the Indian health system. This is laudable but may not be sustainable. Creating sustainability would involve taking a systems approach to make sure all parts of the system, both of health care and of supportive social care are well functioning.
Also read | Why health care workers above 60 should be ‘benched’
Many health workers are overworked not by choice, but rather the lack of it since understaffing and shortages are a common feature of the Indian public health-care system. In addition, India simply does not have enough health facilities to cater to all its population, even without a pandemic. Further, the lack of adequate social care, such as care homes, community health services and community-based rehabilitative and palliative services, unduly increase the burden on health-care facilities.
Stakeholder involvement
Finally, a systems approach involves all stakeholders. Patients themselves need to be aware of patient safety as well as be empowered to demand safe health care and resist unnecessary medications and procedures. Hospital managers must understand the need for and be empowered to create systems of reporting, monitoring and organisational learning. Policy makers must prioritise staffing, co-designing functional and safe workplaces, and ethics in health care.
Also read | ASHA workers soldier on — unprotected and poorly paid
Numerous persons find healing and restoration in health care. But some are harmed as well. In crises such as COVID-19, quality of care can be compromised further. We can help improve patient safety by taking a systems approach and promoting a culture of health worker safety and well-being.
Dr. Harikeerthan Raghuram is a public health researcher and consultant. Dr. Anant Bhan is a researcher in global health, bioethics and health policy
