Worldwide, medical incidents occur in 10 percent of hospitals, and 50 percent of those incidents that result in patients’ deaths are due to preventable medical errors, according to data from the World Health Organization. In Lebanon, more than one thousand complaints related to medical malpractice were filed to the Order of Physicians between 1996 and 2013. Investigations of medical incidents by the order however, focus mostly on physicians and fail to assess the problem from a macro perspective, where incidents may occur due to failures of complex healthcare systems.
Despite the fact that concerned stakeholders are leading initiatives to resolve this crisis, the associated implications and debates about causes, responsibilities and accountabilities are ill-informed, and in many cases, do not lead to real improvements in patient safety practices.
What are the challenges affecting patient safety in Lebanon?
One way to improve patient safety is by encouraging healthcare providers to report on medical incidents. In Lebanon, research shows that 60 percent of providers refrain from reporting medical errors and near misses. This is because 81.7 percent feel that their mistakes, if reported, will affect them negatively and will be held against them. Also, 82.3 percent of providers are concerned that incidents occurring, even if related to problems in the organization’s system, will be kept in their personal files instead of being used for performance improvement.
There are clearly structural problems that lead to medical incidents, and these problems make improving patient care and safety challenging. Some of these are related to problems at governance level. In Lebanon, there is still no explicit national policy related to quality improvement and patient safety that specifies goals and indicators, clarifies roles and responsibilities, and identifies incentives. There is also no policy in the Lebanese healthcare system that allows for the re-licensing of practitioners. It should be pointed out, though, that there have been some achievements to improve patient safety, notably implementing the national accreditation system by the Ministry of Public Health (MoPH). The system, however, still has some gaps and is currently under revision. Some of the gaps include: outdated standards, non-renewal of accreditation “status” on a regular basis, the absence of mechanisms to ensure quality is sustained post-accreditation and lack of certified national auditors.
Within healthcare organizations, there are gaps and dysfunctions in the area of clinical governance that are affecting the quality of care provided and hence patient safety, allowing medical errors to occur. Gaps include inadequate clinical audits and documentation, inaccurate assessment of performances and processes, and below standard education, training and performance appraisals of providers. Also, the limited use of evidence-based guidelines is affecting the quality of care provided within organizations.
The financing of health care in Lebanon is another critical area that should be improved to enhance patient safety and prevent medical errors. In April 2014, the MoPH established its new financing arrangement for reimbursement of services provided by contracted private and public hospitals. Despite the new system in place, there is still room for further improvement to enhance the financing system and establish links between accreditation status, performance indicators, regulations and contractual agreements. These improvements will engage healthcare organizations and personnel in quality improvement and patient safety initiatives.
At the delivery system level, a patient safety culture, and training of providers on how to lead, implement and follow up on quality improvement and patient safety initiatives are essential, but still not instilled in the day-to-day operations of Lebanese healthcare organizations. This promotes a punitive environment within organizations, and is a major reason why healthcare providers hesitate to report medical errors. The shortages of staffing, especially of nurses, the work overload observed in most healthcare organizations and miscommunication within and across organizations, are additional barriers to endorsing a patient safety culture.
Evidence-based practices: a global perspective
Initiatives from other countries to control incidents of medical errors consist of enhancing clinical governance, integrating anonymous incident reporting, implementing accreditation systems and empowering patients.
Empowering patients increases the efficiency of the healthcare system, helps improve the quality of care and reduces errors
Enhancing clinical governance to improve performance and quality of care has been achieved through: integrating evidence-based clinical guidelines that set standards on how clinical procedures should be performed, continuing education and training of providers, and carrying out regular audits and appraisals of providers’ performances to improve their work and enhance patient safety.
Developing anonymous incident reporting systems in environments that do not have disciplinary implications have been shown to be effective in reducing medical errors. Systems in England and Wales have been found to be effective in identifying errors at a micro level to enhance patient care and safety at a national level. In practice, this work includes raising awareness, doing research, audits, training initiatives, curriculum changes and developing specific guidelines. This approach allows providers to freely report on medical errors, and builds a culture where organizations can learn from one another to improve patient safety and the delivery of care.
Accreditation systems are playing an important role in reducing medical errors. They integrate patient safety goals, indicators and training requirement into their standards. This promotes an increase in staff engagement and communication, an improvement in organizational efficiency and progress in leadership and staff awareness about continuous quality improvement. Linking the accreditation status to reimbursement is an effective mechanism that makes the business case for accreditation.
Empowerment work with patients and their families is being implemented by developing educational material, such as medical flyers and brochures, and conducting awareness campaigns. These tools reduce the knowledge gap between healthcare providers and patients, which result in an increase in agreement and shared decision making. Empowering patients thus increases the efficiency of the healthcare system, helps improve the quality of care and reduces errors and readmission rates.
Implications for Lebanon
Rather than reacting to errors after they have occurred, proactive concrete action should be taken to prevent such errors from occurring in the first place.
Healthcare executives and policy makers in Lebanon should consider the following evidence-based strategies in order to tackle medical errors in Lebanon. The current accreditation system should be revised, patient safety indicators mandated, and a system of incentives that links contractual agreement, regulations, accreditation status and performance indicators should be created.
A national council on clinical governance – including representatives of syndicates, orders, academic institutions, the public and private sectors as well as international bodies like the World Health Organization – should be created. The council should be divided into four committees, each responsible for the following: clinical governance development, including the drafting and implementation of evidence-based guidelines; education and training of healthcare providers; audit and feedback; and performance appraisal.
Context specific evidence-based clinical guidelines should be developed and implemented at the national and organizational levels. Incident reporting systems should be developed, within the first three years at the organizational level and the following years at the national level. Incident reporting should promote non-punitive response to errors and ensure that lessons are derived from errors to prevent them from happening again.
Curricula of healthcare students and trainees’ should include patient safety and quality improvement. Internal medical audit and feedback, performance appraisal, continuing medical education and providers’ recertification should be performed regularly.
Patients and their families should be empowered by conducting awareness campaigns and educational materials should be developed to empower patients and their families. Raising the awareness of media and building their capacity should be done to report on medical errors in an evidence-informed way.