Why HK needs a patient safety agency
S. P. Li has correctly called for more transparency regarding the incidence of medical mishaps in Hong Kong ('Real number of 'error' deaths unreported', February 5).
In view of organisational similarities, the epidemic of medical error in other developed health care systems is destined to be repeated here. As I have explained previously ('At the sharp end', September 24), medical errors are the product of a complex delivery system staffed by necessarily fallible human beings. No unfairness to doctors flows from these observations, but rather the difficulty of their work and the need for systems-based safety programmes are highlighted.
Incredulity is common when the scale of harm due to medical error is exposed (for example, even by conservative estimates, an error in care will cause or contribute to the death of one out of every 300 patients admitted to hospital). Anger and indignation on the part of the public engender defensiveness from doctors, hospital managers and governments. Eventually a co-operative sense of purpose evolves which recognises safety as a priority. This is now just beginning to happen in Hong Kong, but we can learn from the progress made in other countries.
The US Patient Safety and Quality Improvement Act of 2005 was enacted to improve patient safety by the use of confidential reporting of events that adversely affect patients. This law provides for the creation of patient safety organisations which collect, aggregate and analyse reports from health care providers.
The identification of patterns of failures allows proposals to be formulated on measures to eliminate safety hazards. The national quality forum, a collaborative project between providers and patients' groups, has identified a set of serious, preventable adverse events that form the basis for a national reporting system. Federal legal privilege and confidentiality protection apply.