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( By Dr Aniruddha Malpani )

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Chapter 9 - Minimizing risk, Maximizing safety

Dr Rajan Madhok, Medical Director, NHS Manchester, ENGLAND and GAPIO Lead on Patient Safety (

Dr Nikhil Datar, Consultant Gynaecologist, Hinduja Hospital, Mumbai

Ramesh Sawant was in a deluxe suite in a corporate private hospital, recuperating from the multiple injuries he had sustained in a car crash. Just when he seemed to be getting better, he acquired an HCAI (healthcare-associated infection). Who was responsible for this? The doctors, the hospital staff, or his relatives? Can Information Therapy prevent such incidents from occurring?

What is patient safety?

Hippocrates, the father of medicine, exhorted doctors to ensure that their patients did not suffer unnecessarily and his dictum, 'First, Do No Harm' (Primum non nocere), has been the guiding principle for doctors worldwide. Medicine in those days was empiric and literally a 'hit and trial' affair, which is why such a caution was needed. With the recent dramatic advances in science and technology, most people naively assume that although modern medicine cannot cure everything, it must be much safer. Whilst they would be largely right, it is wrong to assume that modern medicine is completely safe. 21st century medical care is much more complex, so organising and delivering it safely is a major challenge. Medical knowledge is evolving rapidly, making it difficult for doctorsto keep up with newer trends. Since there are so many different players involved now (primary care physicians; organ specialists; nurses; physician assistants; hospitalists; technicians; medical informatics specialists; and administrators), there is limited understanding of how healthcare systems can be made to function smoothly.

Compared to other safety critical industries (especially aviation), medicine has not yet fully adopted the principles and practices necessary to ensure that complex healthcare can be delivered safely. The Institute of Medicine's report 'To err is human' assessed that modern healthcare was the sixth leading cause of death; and that more deaths were caused by iatrogenic errors, as compared to breast cancer or road traffic accidents in the USA (Accessed 7 August 2011 It has been estimated that almost one in ten patients suffers an adverse event in the hospital; and there is a one in 300 chance of dying in a hospital due to a medical error. Modern medicine is clearly a two-edged sword: on the one hand it can alleviate suffering and on the other hand it can cause harm. Patient safety therefore has become an important public health issue.

How can Information Therapy help to ensure safer care?

Let us take one example to see how this may work.

Healthcare-associated infections (HCAI), acquired in a hospital or clinic, are the most frequent adverse events in healthcare delivery worldwide. Millions of patients are affected by HCAI worldwide each year, leading to significant mortality and financial losses for health systems. Of every 100 hospitalized patients at any given time, 7 in developed and 10 in developing countries will acquire at least one kind of HCAI.

The burden of HCAI is also significantly higher in low-income countries than high-income ones, especially in intensive care units and in neonates. For example, newborns are at higher

risk of acquiring HCAI in developing countries, with infection rates three to 20 times higher than in high-income countries

(From fact_sheet_en.pdf accessed 7 August 2011).

Practicing good hand hygiene is a simple measure that can drastically reduce the chances of getting an HCAI. This led the World Health Organisation (WHO) to launch a global campaign to improve hand hygiene among healthcare workers: 'SAVE LIVES: Clean Your Hands' is a major component of 'Clean Care is Safer Care' and can help reduce the spread of potentially life-threatening infections in healthcare facilities.

This is not a new revelation, and the benefits of hand hygiene have been well documented in the past. Semmelweiss in 1847 demonstrated that obstetricians could considerably reduce the number of women dying after labour by simply washing their hands between deliveries. However, he had great difficulty convincing his colleagues to do so and wash ounded out of his hospital attachments for daring to speakout against doctors. Sadly, getting healthcare professionals to change their existing practices has not become any easier since then!

This means we now have a choice. We can continue relying on healthcare professionals to follow good practice to protect patients from HCAI (even though we know that they will often not do so in real life); or we can explore whether patients can do something about it.

This is where Information Therapy can play an active role. It can be used for the following:

  • Advising all patients of the importance of HCAI since not many patients are aware of the magnitude of the problem;
  • Educating patients and their relatives about the importance of hand hygiene and getting them to use disinfectant hand sanitizers while in hospitals. This is especially important in India, where relatives play such an important role in providing nursing care to patients;
  • Making hospitals publish their statistics of hospital- acquired infections. Ideally there should be open reporting of data, showing trends and improvements over time; and Getting patients to request the healthcare professional 'touching' them to wash their hands before doing so.

So, here is a sample Information Therapy prescription for a patient going into a hospital:

  • Please be aware that hospitals are dangerous places and that your hospitalisation can cause you to acquire an infection.
  • You can reduce your chances of getting an infection by limiting the number of your visitors; and by asking them to wash their hands and using disinfectant.
  • Do request your doctors and nurses to wash their hands before touching you or doing a procedure.

This kind of openness and transparency can empower patients; and reinforce the fact that the hospital is doing all it can to ensure that patients are safe and that the risk of errors is being actively minimised.

The Planetree model ( is an excellent example of how hospitals can significantly improve patient outcomes and reduce patient errors by actively involving patients (and their family members) in medical care. It is the patient who has the most at stake; and by ensuring that patients are well informed, hospitals can help to reduce complications and errors considerably. This will improve patient satisfaction scores and increase patient loyalty, which in turn will result in better hospital occupancy and boost their bottom line. It will also help to reduce the risk of lawsuits because of medical errors.

This prescription can be in the form of written notes, or in an audiovisual form since the use of multimedia can improve patients' understanding and retention by over a third. In summary, Information Therapy increases the patient's 'ownership' and helps the patient to explore alternatives by empowering them to choose appropriate care and set realistic goals. The doctor-patient relationship becomes more open, being partnership-based rather than paternalistic; and shared decision-making can be achieved.

Information Therapy is equally useful in the doctor's clinic as well. We all know that often a patient will need to visit different specialists. Unfortunately, as a result of this, care gets fragmented, and problems such as drug interactions are very common. By ensuring that the patient knows exactly what medications he is taking and why, these preventable problems can be avoided with the help of Information Therapy. Information Therapy acts like an immunisation against ignorance. It helps to make sure that things don't fall through 'in between the cracks' and puts the patient back in charge!

Challenges and opportunities for Information Therapy

To make Information Therapy work, we have to address some challenges. First, most people are still unaware of the problem of unsafe care: they believe that modern medicine is a force for good and that doctors and nurses are highly professional people and that they are in 'safe hands'. So we do need to acknowledge that there is a problem and that it is imperative to promote safer care. Second, we still do not know enough about the extent of the problem. How many incidents are occurring? Where? When? What kind? We need to ensure that appropriate data is collected. This will help us to understand the underlying causes of these errors and enable us to design solutions. Finally, do patients or their carers/relatives feel empowered enough to question, and indeed challenge, their doctors? Even doctors often shy away from questioning their own personal doctors when they are ill!

Information Therapy can be a major force in improving patient safety, and we need to create an ecosystem where patients can safely demand that they be given Information Therapy; and doctors can feel comfortable doing this routinely and proactively. Today, there are a number of organisations and initiatives to promote the involvement of patients in improving healthcare safety.

WHO Patients for Patient Safety: Patients for Patient Safety (PFPS) emphasises the central role of patients and consumers in improving the quality and safety of healthcare around the world. ( patient/en/).

Action against Medical Accidents: Action against Medical

Accidents (AvMA) is an independent non-profit organisation that promotes better patient safety and justice for people affected by a medical accident. A 'medical accident' is where avoidable harm has been caused as a result of treatment or failure to treat appropriately. (

Technology can help as well. We are learning how to design and deliver better healthcare, by looking at system designs, and hence are able to identify and eliminate steps where mistakes could occur. Information Technology has a very important role - by having a unique identifier for every patient, and a single electronic health record, we can provide timely and accurate information to both patients and their doctors.

The delivery of the right information, at the right time, to the right patient, by the right doctors and nurses should no longer be left to chance; every patient should get this routinely as part of their care in the 21st century. Sir Muir Gray, the Chief

Knowledge Officer of the NHS in England, talks of high- quality information provided directly to the patients being the way forward for the transformation of healthcare. In the recent reforms being proposed by the Government in the NHS in England, the Minister has made it clear that he wants a health service where patients are in the driving seat, not as passive recipients of care but as equal partners with healthcare professionals - 'No decision about me, without me' - and this cannot happen without huge doses of Information Therapy. Let us use the opportunities available to us to overcome the challenges and get the care that we all want and deserve for ourselves and for our dear ones.