DOCTOR Catherine Crock knows better than most that hospitals can be dangerous places. The leading physician has seen her fair share of medical errors in a 31-year career, including some she has made and learnt from.
When Crock was admitted to hospital recently for a small procedure, she couldn't help focusing on routine safety measures such as staff washing their hands between patients, checking identification tags before taking blood, and keeping medical histories up to date so crucial changes are detected in a timely fashion.
''Some of these things weren't being done, and at one stage I even saw a mix-up with two patients' histories. I kept noticing things in the area I was sitting and I thought, 'Should I mention it to them or not?' It made me nervous about my safety,'' she said.
Crock was also worried about signs of tension between staff whizzing through their work to get to the next patient needing attention. Having worked in teams, she knew how crucial collaboration was for safe and efficient care, so even minor bickering among the staff bothered her.
''It's a bit like watching people [working] in a restaurant. If they're fighting, you start wondering if the coffee's going to be cold,'' she said. ''How can you trust them if their house is not in order?''
The coffee example may seem slight, but the restaurant analogy is appropriate, given the common fear that you will be punished for sending back an unsatisfactory order. Complaining about minor medical mistakes may seem similarly fraught, but the consequences of such disharmony in the health system can be dire. Every year, at least one in 10 Australian patients will experience an adverse event in hospital - unwanted and usually harmful incidents that must be acknowledged if staff are to prevent them from happening again.
Extreme incidents that have been widely reported include surgeons operating on the wrong body part, or a pregnant woman having disinfectant accidentally injected into her spine instead of an epidural. Hundreds of thousands of others receive no publicity, such as a prescription error that resulted in a child receiving chemotherapy eight months longer than they should have, or an elderly person who picked up a life-threatening infection from a bed sore that would never have happened with more thorough care.
The most common cause of these errors is a breakdown in communication between patients and staff, or among staff themselves during clinical handovers, of which there are millions every year during shift changes. According to the Australian Commission on Safety and Quality in Healthcare, about half of all medication errors occur during these transitions in care.
The possibilities are endless and often so subtle that they would be untraceable if someone tried to work out where things went wrong. A hurried conversation, for example, might make a patient skip over some crucial details when a doctor asks about their symptoms to make a diagnosis.
While hospitals are already using many proven methods such as checklists and peer reviews to prevent errors, there is a growing feeling in the health sector that patients can and should play more of a role in their care to prevent mishaps.
Crock, who has worked in adolescent health and haematology at the Royal Children's Hospital for many years and who also directs the Australian Institute for Patient and Family Centred Care, says an increasing number of hospitals around the world are preventing errors by empowering patients and their families to participate more. Some are inviting patients to check their medications, for example, or have their family members measure their temperature or how much water they are drinking to ensure it is being done. Others are telling patients to ask their carers if they have washed their hands before they touch them. There has also been a move to put patient representatives on hospital committees, including those that make decisions about health professional job applicants.
After all, Crock says, patients and their families are well placed to see things that work and don't work. While hospital staff are usually thinking about dozens of patients at the same time, as well as their colleagues and what is happening in their private life, patients and their families are sitting around for hours on end noticing look-alike medication bottles and inconsistent advice from different doctors. ''The patient and family are the constant across all changes of care and location within the system. Collectively, they are a significant resource of valuable information that the healthcare system needs to tap into,'' she says.
One hospital that has achieved results from mobilising patients is the Dana-Farber Cancer Institute in the US. A few years back, staff decided to encourage patients to cross-check their care more often and speak up if they noticed anything wrong. A campaign was run with the slogan ''Check, Ask, Notify'' on posters to remind people to participate.
When staff surveyed more than 2000 patients about their experience, they found a strong link between active participation and fewer adverse events. The survey asked patients about their illness, how often they spoke with doctors and nurses about it, whether they had relatives or a friend to help them make decisions and express their wishes, and if they ever checked things such as the medication they were being given. When the researchers looked at their medical records, they found that patients who scored highly on these measures had half the rate of adverse events in hospital compared with others.
Victoria's Health Services Commissioner, Beth Wilson, has seen many cases where patients or their families may have been able to prevent problems in the health system. She often hears about incidents where people saw missed opportunities.
''I've heard people say, 'I knew my baby was sick, I just knew it' after something has gone horribly wrong … It's powerful stuff. In some cases they felt afraid to speak up or they did speak up and were ignored.''
Wilson says most people feel disempowered by a paternalistic culture in hospitals and clinics where doctors have always known best. There are visible hierarchies everywhere. Surgeons and senior medical specialists boss junior doctors around, who in turn tell nurses and administrative staff what to do.
Wilson says the culture not only makes people scared to speak up out of fear that they will offend or embarrass someone, but they also think they might be punished for it or get someone sacked.
''I frequently see people telling me about an incident but not wanting to make a complaint because they don't want to get people into trouble,'' she said. ''We need to change the culture, and culture is often created by the language that is used. I've noticed that some healthcare workers are now being told not to call patients names like 'sweetie,' 'dear' or 'mate'. I'm sympathetic to that because I don't want someone calling me 'sweetie' while they put a suppository in me. If you're calling someone 'sweetie' or 'dear', you're talking down to them. Health professionals need to think carefully about the way they communicate with people. It needs to be respectful.''
Wilson says the paternalistic culture is also undermining the law of informed consent, which says people should be told as much as is necessary for them to be able to make an informed choice about their care.
''It does not happen anywhere near enough. A lot of hospitals seem to think that a signature on a form is informed consent. I've noticed in hospitals that where consent used to be a noun, it is now a verb, so people will say, 'Has she been consented yet?' Consent was something you used to give, but now it's something that is done for you. That practice is quite different to what the law says.''
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