26.02.2020 “People have a right to know how safe our health system is”

The Patient Safety Foundation draws attention to adverse events in medicine without pointing the finger at individuals. Its aim is to change the system so that events of this kind don’t happen again, explains Dieter Conen, the Foundation’s President.

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Dieter Conen

Professor Dieter Conen first studied philosophy and then medicine. He wrote his doctoral thesis in 1984 on the subject of the “Quality of doctors’ services”. From 1987 to his retirement in 2008 he headed the Department of Internal Medicine at Cantonal Hospital Aarau and was a professor in the Faculty of Medicine at Basel University. He was a member of the Hospital Council of Zurich University Hospital and is the Founding President of the Swiss Patient Safety Foundation.

Mr Conen, according to the website, your Foundation wants to achieve a “constructive and systematic safety culture in the health service”. What do you understand by safety culture?

It’s not easy to define a safety culture. Our concept follows the ideas put forward by Edgar Schein when he coined the phrase organisational culture. Reduced to one sentence, his definition states: the culture of an organisation describes how tasks within this organisation are done. Applied to safety, this definition means that culture comprises far more than the measures and standards that are employed.

We believe there are five aspects to safety culture. The first is leadership. The development of a safety culture is the responsibility of management and requires the commitment of all levels of management. The second point covers issues relating to an adequate level of staffing. Thirdly, are procedures standardised, specified and routine? The fourth point relates to the measurement and documentation of procedures. A hospital must have tools suitable for establishing what is working well and where mistakes are happening so that it can learn and improve. And finally, the fifth point is that communication must be transparent within the hospital and from the inside out. Because communication problems usually play a central role in adverse events. 

Is there a safety culture in all health facilities?

Yes, but they are at different stages of maturity. The highest level in a culture of patient safety is achieved when all processes are examined for their relevance to safety and their potential risks, and optimised continuously. 

How often do accidents happen?

Our data is not recorded prospectively; it is generally compiled retrospectively, so we can’t exclude the possibility of distortions. The data shows that between 90 and 95 per cent of all hospital stays are unproblematic. In 5–10% of cases the medical procedures don’t turn out the way they should. In about half of these adverse events, something went wrong that had nothing to do with human failure, but around one third to half of these cases are due to an error – which means they were avoidable. 

The Patient Safety Foundation was set up in 2003. What has it achieved?

We have made patient safety a subject that people are talking about. It’s very important that we have understood how to talk about critical and in some cases tragic events without turning them into a scandal. We have been able to explain that it’s not about bad people who cause harm. It’s about people who work in poorly functioning systems and therefore sometimes unfortunately cause harm. This is why our emphasis is not on punishment (unless the harm was due to gross negligence) but on improving the system. 

What has the Foundation not achieved so far?

We carry out our pilot projects with a modest number of hospitals. We don’t have the resources to expand our scope. We would like, for example, cases in which medical harm occurs to be recorded on a country-wide basis. We have not achieved this goal so far for a number of reasons. And that’s why we don’t know the full extent of this harm. In Switzerland nobody knows, for example, how often surgery is performed on the wrong side of the body, or a foreign object is left behind. 

But the Foundation does have an error-reporting system?

Yes, but at the moment our reporting system is set up in such a way that it only covers events that don’t result in harm. We make a clear distinction here because errors that lead to harm raise questions of liability. We don’t want voluntary reports to work to the disadvantage of the people submitting them. 

You once referred to yourself as a “medical citizen who enjoys doing his duty towards patients”. What sort of duty do you mean?

A citizen should not spread lies, he should be open and transparent and have a sense of responsibility towards his environment and for upholding the common good. The same applies to doctors. They ­shouldn’t hide behind their professional credentials but should try and do whatever possible for their patients and, to a certain extent, be their advocates. This works well on an individual level because doctors generally have an intrinsic motivation, do their best for patients and feel responsible for them. But at the systemic level there is often resistance from the medical profession. 

How do you explain this?

While a future doctor is studying medicine, the emphasis is on the individual contract between doctor and patient, and the freedom to choose a therapy is a major element in the doctor-patient relationship. Yet at the same time, doctors also have a responsibility to society because society is providing the resources. The medical professional also has public health tasks, one of which is patient safety. If harm leading to death occurs, I need to know how often these events occur. At the same time I need to know what I can do to prevent these events from happening, or at least to mitigate their effects.

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