Marlene - Philosopher
Today, 17th September, has by WHO been coined World Patient Safety Day, acknowledging the fact that patient safety is still a global health priority. Although we have come far from where we were twenty years ago, at its beginning, we are still not there. In 1999 the US based Institute of Medicine report To Err is Human claimed that between 44.000 and 98.000 patients in the US die every year from preventable adverse events. This claim was based on the result of a study of pervasive medical error in the US(1), later supported by another US based study(2). These studies were followed by Australia(3), Denmark(4), Britain(5) and a Canadian study in 2004(6), suggesting that adverse events are in fact an international problem. Several of the adverse events identified in these epidemiological studies were estimated to be avoidable. Hence, the beginning of "patient safety" as a term, and as movements to support and improve patient safety began, so did the complexity and dilemmas of how. How do we achieve patient safety? And specifically for us at CAMES, was simulation a viable way forward?
From a philosophical and ethical point of view, I believe that patient safety and the promotion of safety cultures, as we still work towards, is an ethical claim - a normative project – "patient safety ethics". We are obliged to work for patient safety, and healthcare systems are thus accountable for providing safe healthcare at all levels. The opposite would be alarming to say, "we don't want safety for patients"! But is safe possible?
Ethics is about "what we ought to do" it is about the fundamental principles that define our values and determines our moral duties; it is the individual, organizational and societal beliefs about what is right and wrong. And it is accounted for in our actions. In our behavior. Ethical behavior is about doing that which is morally "right". (Off course in ethics, like in other fields, the right action can depend on the theoretical approach applied.)
It might sound easy, but it is not always. We may, for instance, perform the right actions, but the consequences can still fall negative. We may also be so lucky, that we choose a wrong action, but the consequences fell positive. How do we then evaluate the person (actions)? Consequences vs intentions? How does that person continue his/her path in the healthcare system? We need to be able to accommodate versatility, and acknowledge that situations are often ambiguous in healthcare - when we judge, when we organize, pass laws and when we educate and train with simulation. The ethical claim pertains to all stakeholders. We want to take care of the patients, but we must remember to take care of the healthcare workers as well. What are their working conditions, the realm of possible performance? Are these conditions justifiable from an ethical perspective?
In Healthcare we have what has been known as first (patients) and second (healthcare workers) victims after adverse events, that we need to take care of. What are their needs, how do we support them and heal them? How do healthcare workers cope? How do they disclose and apologize after adverse events? Should they always? And why is it so difficult? Ethics is one thing and Law another, and they do not always match up. Some may want to disclose and apologize but they are afraid of the "system"? They might be afraid of the consequences for their professional path. But is the fear rational etc.? These are themes we keep on returning to, because they are still out there, and we need knowledge, training and local systems to support. It is known that healthcare workers can be traumatized after adverse events, some even leave the profession, especially if they are not supported. These situations are examples of what can be simulated, and we do so in some courses at CAMES. We create opportunities for healthcare workers to train these difficult conversations in a safe environment, by simulating "real life" cases, or even their own. Depending on the issues, we use table top simulations, needs analysis, and many other methods to understand patient safety. These might show that some of the problems in patient safety are structural/organizational – at times; time to prepare for the next patient is missing, at times there are no suitable rooms to take a conversation to name a few examples, or they can lie in beliefs and values of the culture. Bringing in ethics into these different methods may remind us that there can be more complex issues behind what might be disguised as purely professional or personal challenges.
Healthcare is full of complexity and dilemmas, coupled with patient safety it becomes even more challenging. As a philosopher and human factors expert I engage in the complexity and use different methods and theories from various fields to deconstruct and comprehend patient safety issues. As a philosopher I am trained to attempt to understand a problem on all levels, from the metalevel to the very near local specific context; as in "work as is", and from all involved parties' perspective. (It is essential to me to create the full picture to give qualified perspectives/solutions/research questions on different themes.) I find that this philosophical competence often makes me notice things others don't see. I believe that our multidisciplinary team at CAMES is a rare asset. We complement each other and can innovate on patient safety issues, be it research, simulation, education or quality improvement work, all of which feeds back into improving our simulation efforts.
So, was simulation viable? Yes, as it has shown to improve patient safety. The question then is - is simulation an ethical issue pertaining to patient safety? If we can train people in safe simulated environments instead of doing the "training" on real patients, shouldn't we? If you through simulation training can prepare healthcare workers for difficult tasks, make them feel safe and competent, shouldn't we? Yes, we should.
(1) Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I [see comments]. N Engl J Med 1991 Feb 7;324(6):370-6.
(2) Thomas EJ, Studdert DM, Burstin HR, Orav EJ, Zeena T, Williams EJ, et al. Incidence and types of adverse events and negligent care in Utah and Colorado [see comments]. Med Care 2000 Mar; 38(3):261-71.
(3) Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The Quality in Australian health care study. Med J Aust 1995; 163:458-71.
(4) Schioler T, Lipczak H, Pedersen BL, Mogensen TS, Bech KB, Stockmarr A, et al. Incidence of adverse events in hospitals. A retrospective study of medical records. Ugeskrift for Læger 2001; 163(39):5370-8.
(5) Vincent G, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. British Medical Journal 2001;322(7285):517-9.
(6) Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ 2004; 170(11):1678-86.