Hospital workers need a culture of safety if Alberta wants to protect patients from deadly errors, says a new report.
Alberta Health Minister Gene Zwozdesky and the Health Quality Council of Alberta released a new patient safety framework in Calgary on Monday. The framework is meant to reduce the number of life-threatening mistakes that happen in hospitals.
Alberta's health care workers are top-notch, Zwozdesky said in an interview, but they're also human and make mistakes. We've never had a province-wide incident reporting system, so those mistakes haven't been publicized.
The framework proposes a province-wide adverse event reporting system where practitioners can share ways of spotting and preventing problems — a first for Canada, Zwozdesky said.
Joined to it is a patient/family safety advisory panel that will get patients to share ideas on how to improve safety and a commitment by Alberta's major medical organizations to create a "just and trusting culture," one that would encourage reporting and learning from major mistakes.
These changes should lead to a safer health care system, Zwozdesky said. "It's about creating a culture of trust, not a culture of blame."
Costly errors
The province brought in this framework partially in response to safety problems at Alberta hospitals, according to John Cowell, CEO of the health quality council, such as the poorly sterilized tools and superbug outbreak at Vegreville's St. Joseph's General Hospital in 2007.
About 185,000 acute care visits to hospitals a year result in a life-threatening error, according to a 2004 study in the Canadian Medical Association Journal, resulting in about 16,500 preventable deaths.
This is a systemic problem, according to Cowell: practitioners fear for their jobs if they make mistakes, so they don't report them. When they do, only a small group of people hear about them, so any lessons learned aren't passed on.
Creating a common reporting system should help prevent mistakes by spreading best practices, Cowell said, such as pre-surgery checklists.
"This is not about negligence or criminal behaviour," he said. "People will make mistakes. This is about creating a culture of trust where practitioners can report errors without fear for their jobs."
There are a lot of good ideas in the framework, said Louis Francescutti, professor of public health at the University of Alberta and specialist in injury prevention, but he worried they could fall on deaf ears. "The average health care worker doesn't go to work with the intent to harm someone," he said, and doesn't see safety as a big problem.
Many basic safety measures such as hand washing and checklists still aren't used consistently in hospitals, he said. "Unless we can get a doctor, a nurse, and a radiation technician to realize they're part of the problem, they're not going to look for solutions."
These sort of cultural shifts won't happen overnight, Cowell said — it took the airline industry decades to go through a similar transition. "We're already seeing the error rate drop," he said, citing anecdotal reports and many parts of the framework are now in the works. The patient/family safety panel starts meeting at the end of September and the provincial reporting system will launch next March.
These changes should lead to measurable reductions in medication errors and surgical infections, Cowell said. "The hospital experience will become safer and safer."
The framework is available at www.hqca.ca.
