October 27, 2021
By Renato Discenza
Primum non nocere. For those of you old enough to have taken some Latin in school, this phrase becomes very familiar to most in the vernacular: “First, do no harm”
This small but powerful phrase is attributed to the ancient Greek physician Hippocrates. Every doctor takes the Hippocratic Oath. Maybe you are like me, and you thought these words were embedded in the oath. Nope. While there is little debate they come from Hippocrates, the origin was in a book that is attributed to Hippocrates on treating fevers in a 400 BC tome called “Of the Epidemics”. It reads a bit like a guest article in the Lancet. One physician sharing his insights and learnings with other clinicians.
So, speaking “Of the Epidemics”, I just did a quick Google search before I set to writing this blog post. Since its start in Canada, quickly closing in on two years, COVID-19 has claimed 28,801 lives in less than two years. While we may be close to wrestling this pandemic to an endemic stage, nobody would argue the devastation caused by this virus.
So, if I told you that in ONE year, we lose approximately 28,000 people due to patient harm in Canada we should all be outraged. Just like COVID, perhaps a portion of those deaths was unavoidable or inevitable. But just like COVID, many of these deaths were indeed preventable.
A large modality of these deaths and harm involved medication. Just behind cancer and cardiac-related deaths, death from patient harm is the leading cause of mortality. The impacts on lives cut short, productivity loss, and the psychological impact to healers who lose patients to preventable deaths is equally devastating.
Harm will happen because the system is complex. It involves human beings that are fallible, but equally systems, technology, and nature, all of which have their own failure modes and complexities. Paradoxically, it may be these same elements, people, technology, and nature that save us.
We at HealthPRO don’t presume to know the solution to this systemic problem. But we do know it is a big one and have focused our contribution on helping our members tackle this by contributing where we can and helping reduce the burden on our clinical partners.
One of my earlier jobs was as an automotive engineer. An impactful lesson for driving change on safety in the auto industry came from the infamous Pinto gas tank explosions. While truly horrifying, deaths attributable to this vehicle’s shortcomings range from as low as 27 to as high as 500 over a four-year period. The tragedy and outrage of this case was the prevalence of the economic, technical, and moral arguments that rationalized the inevitability of these deaths. These preventable deaths ushered in a whole different approach to design, manufacturing, cost-benefit analysis, and other factors in automobile safety. Somehow, I have to believe 28,000 mortalities a year has to drive more action?
The recovery from COVID will add additional stress to an already challenging environment when it comes to patient safety. I see three risk factors, that while present before COVID, has intensified to an all-new level of urgency:
1) Health Human Resource (HHR) shortages
2) Surgical delays
3) Medical product and drug shortages
We need to look at different approaches if we are to even start addressing these.
Frontline nursing and healthcare worker shortages need no primer. We all are sadly and painfully aware of the dire situation. While we try to address it by adding and training more healthcare workers, and overall by throwing more money at the problem, I believe a multi-pronged approach is needed. If we do not change how we deliver care – trying to add more nurses, for example – at the rate we need, based on how we provide care today, a solution may be mathematically impossible. We simply cannot train them fast enough if we do not change our delivery of care.
I believe, in addition to training more frontline workers, we also need to grow capacity in other ways. First, we need to look at HHR in a more integrated fashion. We need to tap into the existing pool of trained clinical and technical healers. It seems intuitive that the more advanced care the provider gives, the more years of training that is required. But how many clinicians are working below their full scope of practice? How much training and experience is left untapped? We need to free up doctors by using more Nurse Practitioners. We need to free up Registered Nurses by using other levels of nurses we can train faster. We need to use Personal Support Workers (PSWs) to deliver more care. We need pharmacists to be part of a more intense primary care process. We need paramedics to be used more on the front line of primary care. If all clinicians already trained were working at their full scope of safe practice, we may have an opportunity to train the entry-level and other support roles faster to support care delivery
Another front is to accelerate the admission of trained professionals from other countries. We need to be pragmatic and innovative in having a system that looks for ways of safely bringing on board people trained in care delivery. We have foreign-trained clinicians doing jobs in non-healthcare settings because it takes years – and a significant amount of money in some cases – to get accredited. We are seeing some progress on this in Ontario, but we need to accelerate it; we need to have an honest conversation among government, professional colleges and associations, and accreditation bodies.
We are also facing unprecedented surgical delays. In some parts of the country, we hear reports of 3-4 years of backlog for “elective” surgeries. This was before the fourth wave of COVID. Some of these “elective” surgeries then become emergency surgeries. The collateral harm in delay in terms of decompensation and patient decline just piles onto the health burden. It’s a vicious circle. Here, HHR is being cited as a compounding factor of risk. Yet in some jurisdictions, innovative technologies are being used that safely deliver care with fewer people by using technology and advanced procedures. Where one Operating Room (OR) nurse is needed now rather than three, and where that OR nurse is working to the full scope of their abilities and technology is assisting. Where surgeries are assisted by minimally invasive technology that not only makes the surgeries more efficient but improves outcomes and rehabilitation time, all freeing up HHR.
We need to re-engineer the human factors and recognize, just like in other aspects of society, we may be able to use less direct human resources so those precious few that are available, are free to use their clinical judgment and skills that only a human can provide. This is not about getting rid of nurses or technicians. This is about using the ones we have better. Technology is to augment the people we don’t have.
Closer to home at HealthPRO, we see medical products and drug shortages as a threat to recovery. We have been working with our members, our suppliers, and government to get ahead of this. For example, Propofol a drug commonly used for patients on ventilators, and patients under anesthetic for surgery, has experienced a shortage during COVID-19; this is likely to further impact surgical backlogs. We have been using our national perspective to see where risk can be pooled, and forecasts can be used intelligently to make sure the right products get to where they are needed the most. We see the dysfunctional impacts of hoarding or oversupply when we break out into our sub-groups and all scramble to get the critical drugs or products. Recently at HealthPRO, we were able to prevent a critical shortage of nitrile gloves on one coast of our country by working with members on the other end of Canada to use their over-stock. This avoided the cancellation of elective surgeries.
We were also able to secure a better forecast, so the suppliers have a better chance of getting the right allocation for Canada. Most medical supplies rely on an international supply chain that is already in extreme crisis. Canada will only get so much of any drug or product. If each jurisdiction is in an “every person for themselves” mode we create artificial crisis. Power comes from acting together and pooling risk.
During Canadian Patient Safety Week, it becomes even clearer to me that to achieve primum non nocere, we need to use our national expertise, our trained resources, and innovation in care delivery to get through this period. Trying to simply turn the healthcare capacity crank faster, without better focus on patient safety and better use of collective resources, truly puts patients at even greater harm.