As the saying goes, there is only one thing more painful than learning from experience. That is, not learning from experience.
The adage is particularly poignant in healthcare, where experiences can be especially painful. Thousands of Canadians die in patient safety incidents each year. Many more are harmed while in care.
In most cases, the causes are systemic and remedied inside the health organization where the incident occurred. But what if it then declines, for seemingly legitimate reasons, to share its experience publicly?
“It’s very important that we share learning, we share knowledge and share recognition of risk,” says Wendy Nicklin, CEO of Accreditation Canada. “It’s totally unreasonable to expect organizations or healthcare providers to all learn the hard way.”
In 2011, the Canadian Patient Safety Institute (CPSI) stepped forward to help healthcare organizations around the world learn from each other’s experience. CPSI launched Global Patient Safety Alerts with the support of the World Health Organization. The innovation technology is a searchable, web-based clearinghouse of information and advisories from patient safety incidents.
The alerts system relies on health regions and organizations participating. Yet while the alerts system is gaining traction, many health regions and organizations are not participating.
Nicklin says some organizations remain leery about releasing details of how or why a patient died or was harmed in care. Legal consequences are one concern. Health regions also fear potentially damning stories in the news media. But healthcare’s overriding responsibility, she says, is to improve quality and safety for patients everywhere.
An early participant in Global Patient Safety Alerts was the Institute for Safe Medication Practices Canada. “Our mandate, our vision, is to promote safe practices,” says David U, ISMP Canada’s president and CEO. “Global Patient Safety Alerts allows us an opportunity to share our learnings internationally.”
He acknowledges that ISMP is in a unique position, in that it is distanced from the frontline — from the patient safety incidents that lead to advisories and alerts. But it’s then up to organizations like his, he says, to foster a climate where organizations and providers see the benefits of shared experience.
“We realize that many other organizations might be a little reluctant,” says U. “But we continue to encourage a sharing culture and have seen quite a bit of progress in recent years.”
Nicklin says the quantity and quality of patient safety alerts will evolve and grow over time. For one thing, the system won’t work if organizations blast out their findings from every incident, she says. “You can’t just share everything,” she says. “There needs to be a mechanism by which information is vetted and filtered. “You can’t have these coming out by the thousands. Otherwise people will stop paying attention to them.”
That is a problem that neither the Canadian Patient Safety Institute, nor its Global Patient Safety Alerts, has faced yet. The issue today is breaking down barriers so more organizations contribute to the alerts. Fear is the major barrier. But David U believes much of it is unfounded.
His experience is that people want and appreciate full explanations after incidents occur. The public, he says, understands that modern healthcare is complex, fast paced and high pressure. They are also capable of understanding that these incidents are almost never caused by a single caregiver that human error or incompetence is rarely at fault.
Typically, patient safety incidents are the result of unforeseen circumstances or procedures that worked well until the incident occurred. It is the one case in a thousand — or 10,000 — that leads to a patient being harmed.
David U says the public and media want the full story, including the details of the incident. They also deserve to know the experience gained and changes made as a result. Trying to hide information is counter-productive and often the cause of public mistrust and media skepticism and scrutiny, he adds.
“The more secrets an organization tries to keep, the more suspicious people will be,” he says. “People will think: Why are you not telling us? It’s a vicious cycle.”
But as he says, a greater good is served if hard-earned lessons are shared; if pain and suffering are reduced for patients in other parts of Canada and the world. “My understanding is that the information we posted to Global Patient Safety Alerts has been accessed quite often,” says David U. “We’re very proud of that and we encourage other organizations to get involved.”