Guest editorial--Primum non nocere (First, do no harm): How do we improve patient safety?

In Canada, more deaths occur from adverse events in hospitals than from breast cancer, motor vehicle accidents, and AIDS combined,[1] and many of these adverse events have been judged preventable.[2] Every day, thousands of errors occur in the Canadian health care system. Fortunately, most do not result in serious harm. Only a small proportion of these errors cause injury, disability, or death and are brought to public attention. We do not commit these errors intentionally, but with the increasing complexity of health care delivery, our patients are increasingly exposed to actions or non-actions that cause harm. So what can we do about this huge problem?

Our traditional approach has been to identify the people making the error and to punish them; however, it has become increasingly clear that we can be more productive focusing on the systems used to provide care. If these systems can be set up in ways that make errors less likely and that catch those errors that do occur, the safety of our patients will be substantially improved.

While much attention has been focused on errors that occur in hospitals,[2] errors are by no means limited to hospital settings. Errors in follow-up and diagnosis are especially important in nonhospital settings, where the number of patient encounters considerably exceeds those in hospital settings and the number of errors is likely to be greater.[3] Opportunities to im¬prove health outcomes in the outpatient setting are likely to exceed those seen in hospitals.

In this issue on patient safety, we have highlighted the extent of the problem and some of the possible solutions. In the first article, Drs Ross Baker and Peter Norton build on their landmark 1994 paper and discuss adverse events in Canadian hospitals. While it is oddly reassuring that Canada is as bad as everywhere else, it is also plain that we do not have enough evidence yet to solve the problem.

In the second article, Dr Bruce Carleton and Ms Anne Smith consider errors associated with the administration of medication. This has long been recognized as a leading cause of adverse events (second most common in the Canadian Adverse Events Study), and that the problem goes much further than just accidentally administering the wrong drug or wrong dose of a drug. Adverse drug reactions can have debilitating and lethal consequences, and rank as one of the top 10 causes of death and illness in the developed world,[4] claiming 100 000 to 218 000 lives in the United States annually.[5]

The third article in this issue de¬scribes the launch and the progress to date of the Canadian Patient Safety Institute (CPSI)—a significant federal initiative to provide real improvement in patient safety. The institute is now responding to the need for a clear expression of national goals and standards, and a significantly enhanced investment in training, technology, and the expansion of research into the complex field of patient safety. CPSI staff and stakeholders know there are unlikely to be simple solutions to current safety problems.

While advancing technology is one of the causes of increasing complexity in health care, it may also offer part of the solution to error prevention. In the final article in this issue, Dr Mark Ansermino takes a rather philosophical look at how technology may have an impact on patient safety in the long term. Reducing errors re¬quires that clinicians be made aware of the magnitude of the problem and recognize that this is a normal risk of fallible human behavior. We need to change the way we work and to recognize that we are able to make things better.

Patient safety can only be achieved by working toward a culture of safety that focuses first on patients, and by completing more research to determine which interventions actually change outcomes.[6] Improvement in patient safety requires a new mindset capable of recognizing that real solutions will come from an understanding of the hidden opportunities behind the errors.

—Dr J. Mark Ansermino, FFA, MMed, MSc, FRCPC
Assistant Professor, Department of Pediatric Anesthesia, 
University of British Columbia
Director of Research, 
Department of Pediatric Anesthesia, British Columbia Children’s Hospital 
—Bruce C. Carleton, PharmD
Associate Professor, Faculty of Pharmaceutical Sciences, University of British Columbia
Director, Pharmaceutical Outcomes and Policy and Innovations Programme, Children’s and Women’s Health Centre of British Columbia 
Senior Clinician Scientist, Child and Family Research Institute, Vancouver

Acknowledgments
The authors would like to thank Ms Natasha McCartney for her valuable assistance preparing the manuscripts.

References

1. Health Care in Canada 2004. Canadian Institute for Health Information. Ottawa, ON; 2004:31. http://secure.cihi.ca/cihiweb/products/hcic2004_e.pdf (accessed 5 June 2006).
2. Baker GR, Norton PF, Flintoft V, et al. The Canadian Adverse Events Study: The incidence of adverse events among hospital patients in Canada. CMAJ 2004;170:1678-1686. PubMed Abstract Full Text
3. Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA 2003;289:1107-1116. PubMed Abstract Full Text
4. Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: A meta-analysis of prospective studies. JAMA 1998;279:1200-1205. PubMed Abstract Full Text
5. White TJ, Arakelian A, Rho JP. Counting the costs of drug-related adverse events. Pharmacoeconomics 1999;15:445-458. PubMed Abstract
6. Forster AJ, Shojania KG, van Walraven C. Improving patient safety: Moving beyond the “hype” of medical errors. CMAJ 2005;173:893-894. PubMed Citation Full Text