On the occasion of World Patient Safety Day, which falls on 17 September, Newspoint meets Mr Stephen Ebejer, a resident academic at the Department of Nursing within the Faculty of Health Sciences, who is undertaking PhD studies around aspects of patient safety.
Why is patient safety under the limelight today?
In 2019, WHO declared 17 September as Patient Safety Day.
When safety is compromised or jeopardised, a serious threat is posed to patients’ wellbeing. Consequences may not be always harmful, but at times the damage might be irreversible or even fatal. Patients and their significant others suffer directly, but also the health care professionals involved in that particular incident are secondary invisible victims of lack of safety. World Patient Safety Day allows us to stop and reflect on the multitude of error repercussions, yet at the same time, focus on a breath and extent of opportunities to ensure safe delivery of care.
How is your doctoral research study linked with patient safety?
The undergoing research focuses on the learning from experiences of workplace errors at three levels: personal, professional, and organisational. Human error is inevitably part of human nature and it therefore forms part of any organisational activity, whether it is recognised or not. In traditional workplaces, errors are often regarded as dreadful and dangerous occurrences because they are seen to be a deviation from established work patterns, which impact workflow and thus are perceived a threat to efficiency.
My research work draws upon two contentions; (1) A substantial portion of workplace errors are preventable and (2) errors could be better positioned as a potential resource for learning.
Why are errors the focal point of your research study?
As much as errors are part of human nature, they are inherent to learning, and an unusual organisation resource. The value in studying errors and how we can learn from them is because errors may initially present themselves as early warning signs and if they are given importance from the onset and addressed accordingly, their occurrence may be translated into a tool towards avoiding larger intensified errors.
In this manner, errors become favourable opportunities to gain valuable learning.
The bottom line is to not eliminate all errors, but to enable learning from them. In this manner, healthcare workers can improve the quality and safety of the care they provide.
What are some interesting findings you’ve encountered in your research so far?
Errors happen within any work and organisational context. No one enjoys having (committed) errors pointed out, and admitting errors can be emotionally unpleasant triggering the natural cycle reaction of disassociation, denial and a blame cycle. However, if addressed appropriately, in a psychological safe environment, then errors start off a healthy discussion which may result in fruitful learning. This reinforces the need for psychological safe spaces in which open communication channels are encouraged, and transparent sharing without fear or inhibition of possible penalisation is accommodated.
Another finding is the lack of shared learning across different departments, or across the whole health care. For example, a fall of a resident in the community offers lessons that can be learnt from that incident, which if shared across other health services, similar incidents in the future could be prevented.
What are some of the hurdles with which healthcare workers operate?
Culturally, in healthcare, when someone makes an error, that becomes understood equivalent to incompetence.
We know that health care professionals are intrinsically in the profession because they want to help people and inclined to offer the best possible care to each patient. Therefore, errors do not happen only to bad people, as errors happen all the time in every work environment. Hence, the growing emphasis is on errors to be leveraged as learning opportunities.
Establishing a learning from error culture helps organisations to rapidly acquire knowledge and use it successfully to sustain, and improve, delivery of safe care is a major hurdle. This should be consistent with the continuously changing environment in which healthcare systems operate. Oddly, hospitals around the globe are not the best examples of how employees try and fail to push the status quo.
What is the biggest misconception in the common understanding of patient safety?
Patient safety sometimes is solely accredited to particular individuals or departments. More constructively, patient safety should be regarded as an integrative and inclusive approach whereby all key stakeholders are equally involved in both the prevention of, and the learning in the aftermath of, errors.
Has patient care improved or gotten worse since COVID-19 hit the world?
Certainly, people have become more aware of ‘invisible threats’ to safety which has further offered an unprecedented opportunity to invent, apply, or reinforce techniques both in public and private places, to enable people to feel and be safe.
#uniteforsafecare is the chosen hashtag for this year’s World Patient Safety Day. What awareness is being raised?
Firstly, individual awareness of surroundings and for safety risks of fundamental importance.
Pointing out concern regarding a risk to patient safety, discussing them openly, may prevent a potential cascade of errors and problems. In the aftermath of errors, taking responsibility is making sure the right lessons are learnt at the right time.
Secondly, for this to happen, employees need to feel safe to share concerns. At an organisational level, people need an open transparent culture in which staff who speak up are supported in raising their concerns. This entails a non-blaming or finger pointing approach and sustained practical help and support.
Thirdly, at a national level, policies should be developed which make employees feel confident at an individual personal and professional level. Furthermore, policy action are needed to encourage a widespread discussion of the learning from errors across multiple areas, in the spirit of higher and common good in supporting the wellbeing of patients and the wellbeing of the professionals.
In tandem with my doctoral studies the UM is actively participative in this important field through the introduction of a Postgraduate Certificate in Patient Safety and Clinical Risk Management , led by the Faculty of Health Sciences.