Unsafe healthcare is an ongoing problem

Medication errors, including prescribing the wrong dosage, are among the issues involved in patient safety. — Filepic

The axiom that all medical students are taught is “Primum non nocere (First, do no harm)”.

That there are risks to healthcare delivery since the end of World War 2 was stated succinctly by British senior consultant paediatric nephrologist Sir Dr Cyril Chantler in 1998: “Medicine used to be simple, ineffective and relatively safe.

“It is now complex, effective and potentially dangerous.”

The magnitude of the harms caused by healthcare delivery were unknown until the 1990s, when many countries reported on the harm and deaths from medical errors.

The publications of To Err is Human: Building A Safer Health System and An Organisation With A Memory: Report of an Expert Group on Learning from Adverse Events in the NHS in the United States in 1999 and the United Kingdom in 2000 respectively, together with similar reports from Canada, Australia, New Zealand, Denmark and some developing countries, drew global attention to the prevalence and consequences of medical errors.

The World Alliance for Patient Safety was established by the World Health Organization (WHO) in 2004.

In Malaysia, Puan Sri Dr HO Wong and this writer convinced the government to establish the National Patient Safety Council (NPSC) in 2003.

Healthcare harm

WHO defines patient safety as “a healthcare discipline that emerged with the evolving complexity in healthcare systems and the resulting rise of patient harm in healthcare facilities.

“It aims to prevent and reduce risks, errors and harm that occur to patients during provision of healthcare.

“A cornerstone of the discipline is continuous improvement based on learning from errors and adverse events.”

The global scale of adverse events from unsafe care is summarised by the WHO’s fact sheet: “The occurrence of adverse events due to unsafe care is likely one of the 10 leading causes of death and disability in the world.

“In high-income countries, it is estimated that one in every 10 patients is harmed while receiving hospital care.

“The harm can be caused by a range of adverse events, with nearly 50% of them being preventable.

“Each year, 134 million adverse events occur in hospitals in low- and middle-income countries (LMICs), due to unsafe care, resulting in 2.6 million deaths.

“Another study has estimated that around two-thirds of all adverse events resulting from unsafe care, and the years lost to disability and death (known as disability-adjusted life years, or DALYs) occur in LMICs.

“Globally, as many as four in 10 patients are harmed in primary and outpatient healthcare.

“Up to 80% of harm is preventable.

“The most detrimental errors are related to diagnosis, prescription and the use of medicines.

“In OECD countries, 15% of total hospital activity and expenditure is a direct result of adverse events.

“Investments in reducing patient harm can lead to significant financial savings, and more importantly, better patient outcomes.

“An example of prevention is engaging patients; if done well, it can reduce the burden of harm by up to 15%.”

In Malaysia

Whilst there are limited publications of Patient Safety in Malaysia, some worrisome reports are mentioned below.

In a review of all patient safety incidents in public hospitals reported in the NPSC’s e-Incident-Reporting System from January to December 2019, “the mean reporting rate was 2.1/1,000 patient bed-days or 1.5% of hospital admissions” – a paltry figure.

It continues: “The major category of incidents was drug-related incidents (32.4%).

“No-harm incidents contributed to 56.1% of all the incidents, while 1.1% resulted in death.

“More hospitals in the eastern and southern regions had low reporting rates, compared to the central region.

“Incidents with severe harm or death outcomes were associated more with males than females, and with the emergency, internal medicine, obstetrics and gynaecology, and surgical departments.”

In a survey of a cluster hospital (the state hospital and two district hospitals) in Kedah, from December 2019 to February 2020, it was found that only 23.9% of the 1,814 respondents had positive patient safety culture levels.

The authors concluded that the “healthcare professionals at the cluster hospital showed unsatisfactory patient safety culture levels.

“Most of the respondents appreciated their jobs, despite experiencing dissatisfaction with their working conditions.

“The priority for changes should involve systematic interventions to focus on patient safety training, address the blame culture, improve communication, exchange information about errors and improve working conditions.”

In an analysis of patient data of 341 randomly-selected patients who visited Hospital Universiti Sains Malaysia’s Emergency Department over a nine-week period, it was found that 95 (27.9%) had at least one medication error.

The frequency of the errors was 30.5%.

The most common types of medication errors were wrong time error (46.9%), unauthorised drug error (25.4%), omission error (18.5%) and dose error (9.2%).

The drugs most frequently associated with these errors were analgesics (painkillers).

No adverse event was observed.

A review of 1,753 medical records randomly selected from 12 public primary care clinics by family physicians for diagnostic, management and documentation errors, potential errors causing serious harm, and likelihood of preventability of such errors, found that “the majority of patient encounters (81%) were with medical assistants.

“Diagnostic errors were present in 3.6% of medical records and management errors in 53.2%.

“Medication errors were present in 41.1% of records, investigation errors in 21.7% and decision-making errors in 14.5%.

“A total of 39.9% of these errors had the potential to cause serious harm.

“Problems of documentation, including illegible handwriting, were found in 98.0% of records.

“Nearly all errors (93.5%) detected were considered preventable.”

Some adverse events are reported, while others are not.

The more serious adverse events result in patient harm, and even death, which can lead to legal suits that the Health Ministry’s Medico-Legal unit is conversant with.

One example is the Hospital Sultanah Aminah fire in Johor Baru in 2016, which resulted in six deaths.

In short, patient safety has been, is and will continue to be a healthcare issue in Malaysia.

Left out of White Paper

The Health White Paper (HWP) purports to “highlight the challenges faced by our health system and proposes solutions for a higher quality, more sustainable and resilient health system as a phased reform over a 15-year period”.

Yet, there was no mention of a safer health system in the HWP – this was a monumental omission.

It is sheer naivety, to put it mildly, to envisage that patient safety will not be an issue in our future healthcare system.

While the public does not expect that healthcare will be risk-free, it is certainly the expectation that all necessary measures will be taken to ensure that the risks of adverse healthcare events are minimised.

Any healthcare provider would be cognisant of the fact that patient harm occurs in healthcare.

It includes, among others:

• Diagnostic errors
• Healthcare-associated infections
• Unsafe surgical care procedures
• Medication errors
• Unsafe injection/transfusion practices
• Wrong patient/wrong site errors
• Venous thromboembolism.

Every Malaysian wants and deserves safe and high-quality healthcare delivered at the right time, every time.

In summary, patient safety is paramount in the current and future health systems.

Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. For more information, email [e-mail]. The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only, and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.