The axiom that all medical students are taught is Primum non nocere (“First, do no harm”).
That there are risks to health care delivery since the end of World War Two was stated succinctly by 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 health care 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” in the United States and “An Organisation With A Memory: Report Of An Expert Group On Learning From Adverse Events In The NHS” in 1999 and 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, Dr H.O. Wong and the writer convinced the government to establish the National Patient Safety Council (NPSC) in 2003.
The WHO defines patient safety as “a health care discipline that emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities. It aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care. A cornerstone of the discipline is continuous improvement based on learning from errors and adverse events”.
Adverse Health Care Events
The global scale of adverse events from unsafe care is summarised well by the WHO fact sheet, for example:
- 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 per cent 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 health care. 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 per cent 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 per cent.
Whilst there are limited publications about 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 2.1/1000 patient bed-days or 1.5 per cent of hospital admissions”, which is a paltry figure.
“The major category of incidents was drug-related incidents (32.4 per cent). No-harm incidents contributed to 56.1 per cent of all the incidents, while 1.1 per cent 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 with more males than females and with the emergency, internal medicine, obstetrics and gynaecology, and surgical departments.” (Global Journal on Quality and Safety in Healthcare (2022) 5 (2): 31–38)
In a survey of a cluster hospital (state hospital and two district hospitals) in Kedah from December 2019 to February 2020, it was found that only 23.9 per cent of the 1,814 respondents had positive patient safety culture levels.
The authors concluded that the “health care 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.” (Patient safety culture and its determinants among healthcare professionals at a cluster hospital in Malaysia: a cross-sectional study. BMJ Open. 2022 Aug 22;12(8):e060546)
“In an analysis of patient data of 341 randomly selected patients who visited the Emergency Department of HUSM over a 9-week period, it was found that 95 (27.9 per cent) had at least one medication error (ME).
“The prevalence of ME was 30.5 per cent. The most common types of ME were wrong time error (46.9 per cent), unauthorised drug error (25.4 per cent), omission error (18.5 per cent), and dose error (9.2 per cent).
“The most frequently drug associated with ME was analgesics. No adverse event was observed.” (Prevalence and characteristics of medication errors at an emergency department of a teaching hospital in Malaysia. BMC Health Serv Res. 2020 Jan 22;20(1):56)
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 per cent) were with medical assistants.
“Diagnostic errors were present in 3.6 per cent of medical records and management errors in 53.2 per cent. Medication errors were present in 41.1 per cent of records, investigation errors in 21.7 per cent, and decision-making errors in 14.5 per cent.
“A total of 39.9 per cent 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 per cent) detected were considered preventable.” (Medical errors in primary care clinics–a cross sectional study. BMC Fam Prac 2012 Dec 26;13:127)
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 which the Ministry of Health’s medico-legal unit is conversant with. For example, the Hospital Sultanah Aminah fire in 2016 resulted in six deaths.
In short, patient safety has been, is, and will continue to be, a health care issue in Malaysia.
Health 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. When there is global recognition that patient safety is a continuing issue in health care delivery, it was ignored in the HWP. This was a monumental omission.
It was sheer naivety, to put it mildly, to envisage that Patient Safety will not be an issue in the future healthcare system.
Whilst the public do not expect that health care will be risk-free, it is certainly the expectation that all necessary measures will be taken to ensure that the risks of adverse health care events are minimised.
Any health care provider would be cognisant of the fact that patient harm occurs in health care. It includes, among others:
- Diagnostic errors.
- Health care 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 health care delivered at the right time, every time.
In summary, patient safety cannot be omitted in the HWP.
Dr Milton Lum is a Past President of the Federation of Private Medical Associations, Malaysia and the Malaysian Medical Association. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation 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.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.