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Patient safety is defined as the avoidance of unintended harm to patients while they are receiving care. Although ensuring the highest levels of safety is a prerequisite for any healthcare facility, and an innate consideration for all those who enter into the medical profession, many complex factors can place patients at risk. Not only can patient safety incidents be a result of systematic challenges within the health system, but they can also be caused by wider issues beyond the healthcare environment, for instance, education and training systems that do not suitably promote and teach the value of safety to medical students.

Dr Sven Staender is all too familiar with the increasing complexity and challenges of addressing patient safety in healthcare. Having realised early on how integral training, communication and teamwork are in the prevention of patient harm, he helped to develop a critical incident reporting system to study errors occurring in anaesthesiology as well as the Helsinki Declaration on Patient Safety in Anaesthesiology. He later helped launch and became president of the European Patient Safety Foundation which is a platform for promoting best practices and knowledge sharing to improve safety. Lorna Rothery spoke to him about his efforts to drive awareness of patient safety in the medical profession and key steps that need to be taken to help raise safety standards across healthcare.

To begin, can you tell me what led you to become interested in the issue of patient safety and engage in the leadership of the European Patient Safety Foundation?

I have been engaged in this topic for almost 30 years. It all started when I began my medical training working in the Department of Anaesthesiology at the University Hospital in Basel. From early on in my career, I realised that patient safety or the safety of our processes in anaesthesiology, while being influenced by technical issues and pharmacological issues, did not really consider human factors. Myself and colleagues began to realise that real progress in patient safety would only be possible when we focus on the aspects of teamwork and collaboration; good communication between healthcare workers is especially important when you are working in an environment where human limitations can contribute to preventable harm.

We developed a patient simulator with psychologists from the University of Texas, the first in healthcare, and replicated surgical settings in the operating room together with surgeons and anesthesiologists. At the same time, we were in contact with the Swiss national airline, then called Swiss Air, because aviation has a long-standing history of dealing with all these aspects of safety and risk management.

I was later involved in the development of a critical incident reporting system as a tool to discuss and address critical incidents that could potentially happen in the operating room. These near misses present huge learning potential and a chance to improve conditions that could be harmful to the patient. The creation of the critical incident reporting system was really the starting point for my patient safety journey. Since then, I have been on the scientific board of patient safety at the European Society of Anaesthesiology, supported the creation of the Helsinki Declaration on Patient Safety in Anaesthesiology and then the launch and early work of the European Patient Safety Foundation, where I was on the advisory board before becoming president.

Do you think the concept of patient safety is sufficiently known, mastered and implemented in most healthcare institutions in Europe?

There are differences across Europe in the way countries approach patient safety. When I look at my own country, Switzerland, we have very limited activities when it comes to teaching on patient safety; I can say that because I run a course in the medical school at the University of Zurich where I teach 24 medical students per year out of a total of 400. It is only a fraction of medical students who are systematically learning about patient safety at medical school. Equally, after medical school, there is no necessity or regulation to learn more about patient safety at all. It is an odd situation since, as a medical doctor, I must complete radiation safety courses every two years, and yet the same does not apply to patient safety despite the scale of errors or mistakes made in hospitals due to human error. The role of human factors in patient safety is not being addressed systematically as it should be.

There is some progress, however, at least in Switzerland where from next year it plans to incorporate patient safety into the education of young doctors before they become specialised.

Patient safety should of course be prioritised across healthcare, but are there any areas in particular where you feel greater attention is needed?
Overall, I do not think the aspect of patient safety should be limited to certain specialities, it must be suitably considered even in rural settings and by private practice doctors. There is, however, a difference between specialities when it comes to the dynamics of healthcare; so, for instance, the pace and demands are different for those caring for the elderly compared to an emergency room or intensive care unit. Dynamics play a role, but the topic of patient safety, overall, is important in all aspects of healthcare.

What resources/people should be mobilised to drive improvements in safety?

Firstly, the difficulty we face is that medical professionals in many specialities believe that simply adhering to their training and having knowledge in their field is sufficient for understanding all aspects of health and safety. We need the concept of patient safety to be more visible and considered; it is limited to think safety risks and mistakes are simply a reflection of one’s own competencies. When it comes to hospitals, but also private settings, most of the time it is communication and teamwork that make the biggest difference and not a matter of how well you are trained. At the end of the day, you must work in teams; you can be an expert in your field but without good communication and teamwork, it accounts for very little in the context of patient safety.

Funding is another issue that needs to be addressed so that we can provide medical students with the knowledge and training needed to support patient safety interventions. When I approach the dean of my university about extended activities to teach patient safety, I am often told that the curriculum is already full and if I want to have an additional course another course needs to be dropped. Funding for major healthcare issues like diabetes, coronary artery disease or oncology has huge amounts of financial support, but funding for patient safety, team training or simulation has next to nothing. This makes a huge difference when it comes to the implementation of educational activities.

In an ideal future, how would you see a hospital organising itself to meet patient safety requirements and achieve the best quality of care?

The future hospital would definitely pay attention to working conditions, ensuring that healthcare workers are comfortable and compensated to enable them to deliver safe healthcare. This would not only involve looking after their wellbeing at work but providing them with education, and training – not only training on facts and figures but on teamwork and communication. We need to train people to be smart enough to work in teams.

We need hospitals where good patient outcomes do not equate to exhausted healthcare staff, and this is a question of resources. Already, we are seeing healthcare staff spread far too thinly and this is going to be a huge challenge for the healthcare system in the coming years.

In previous decades, the main strategy to deal with risk and safety was to increase standardisation. The number of guidelines published up until today is overwhelming, but this leaves out the fact that modern healthcare is a complex system, and we cannot deal with complexity by only following guidelines. As part of our efforts to increase safety, we need specialists to deal with situations where there is no standard or guideline, it is a question of resilience. Simply following rules will not accommodate the complexity and challenges of modern healthcare.

PD Dr med Sven Staender
Past President
European Patient Safety Foundation
http://www.eupsf.org

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Why do you advocate the use of simulation to improve patient safety?

The purpose of simulation is to provide healthcare professionals with a safe environment where they can improve their ability to deal with situations similar to real-life emergencies. In my area of practice and research, namely neonatology and pediatric healthcare, it is widely accepted that such educational methodologies are effective in acquiring and maintaining medical and non-technical skills to recognise and successfully resuscitate critically ill or injured patients. The added value of this kind of approach lies in the fact that medical training focuses primarily on technical skills and individual excellence, whereas other factors, such as the quality and fluidity of communication, leadership, and teamwork, also come into play when dealing with this type of situation. However, due to lack of funding and insufficient staffing, there are still barriers to the wider use of simulation training across Europe, and there are also areas that could be improved, such as a more multi-professional and interdisciplinary teaching approach.

But as medical professionals work together all the time, there should be plenty of opportunities to improve teamwork. So why add it to the list?

Medical teams’ cooperative way of working, in my area but also beyond, is limited by a whole series of factors specific to the work environment of the health sector. It is important to understand that throughout the training and career of a healthcare professional, he or she is pushed to excel. The right to make mistakes is often not recognised and it is all the more present in everyone’s mind because a fault may even be legally sanctioned.

The distribution of roles and responsibilities between doctors, nurses and care assistants also leads each of them to pay attention to only a part of the patient’s reality or care. It is therefore not surprising that cooperation and teamwork need to be trained, and the day when the success of a medical act really depends on it makes you realise that you cannot efficiently work together without proper training. This is a very demotivating situation for health professionals when they know that the quality of care is not up to what they could have given. It should not be underestimated because it can even lead in some cases to burnout and voluntary departure.

In a way, you are pointing to the need for a real cultural change, to move from an individualistic to a cooperative approach to care. Is it reasonable to imagine that a few simulation sessions can turn such an established order upside down?

I am not saying that simulation-based training alone will be enough to revolutionise the approach to care, but it seems to me to be a good start. Sharing what we did well and not so well during a simulation exercise lays the foundation for a useful team dialogue in other circumstances. But, of course, other actions are also needed, in a more holistic and systemic way, as will probably be highlighted during the EUPSF’s Patient Safety Conference organised in collaboration with FOKUS Patient. For example, the principles on which training is based and the way incidents are reported and managed must be rethought and lead to a complete redesign. I am hopeful things will change in the near future because I believe that many health actors begin to understand the limitations of the current system.

By not questioning what the leader says, by not sharing the causes of errors or near-misses, it is obvious that we are preventing ourselves from improving. In fact, as medical caretakers, our goal should be to achieve a way of working as a team in which everyone dares to express themselves and make their contribution to the patient’s health. Promoting simulation is a way of drawing attention to this point, to the fact that it is the interest of the patient and the search for quality of care that must guide the medical approach, and nothing else.

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In light of the Patient Safety Conference taking place in Stockholm in October, Dr. Adriano Friganovic, President of the European Specialist Nurses Organisation (ESNO) and member of the board of directors of the European Patient Safety Foundation (EUPSF), takes a fresh look at the fatigue of the medical staff across Europe and highlights an alternative approach to tackle the crisis.

What if the fatigue – real and widespread – of the medical staff across Europe was only a symptom of a deeper malaise, the extent of which our societies have difficulty in grasping?

What if our belief that the dedication and commitment of medical staff would allow them to get through all pandemics, all hospital shortages, and then get back up again stronger than ever, was in fact pure wishful thinking? What if simple solutions, mainly based on basic recognition and financial incentives, were still needed but no longer enough? What if our healthcare systems were really in danger?

Organisations such as ESNO and EUPSF are determined to address these questions with all the necessary lucidity at the upcoming Patient Safety Conference and to outline courses of action to bring about real change.

What is hiding beyond the real and widespread fatigue of medical staff? What is the problem?

It is not easy to put words to this, and the best thing would probably be to ask them, but I think there is a strong feeling of being misunderstood and of not being supported in professions that are very challenging. I am obviously talking about nurses, whether specialists or not, but also about all the other professions directly involved in medical work, from doctors to nurses’ aides. These are very committed people, concerned to the highest degree with the well-being of others, and confronted with difficulties that we do not even suspect, or that we do not want to see. As potential patients, we are perhaps too easily led to believe that there will always be a dedicated professional who will take care of us with motivation and professionalism. We take it for granted, and this is probably the hardest thing for the medical staff to accept.

Why do you think it is important to look beyond fatigue and draw attention to this malaise?

I am not saying that the fatigue of the medical staff is not a problem in itself. Not a week goes by without a new regional or national survey confirming the very high level of fatigue, or even exhaustion, among health professionals, which can be traced back to the COVID-19 pandemic, pre-existing shortages, or particularly challenging working conditions. This is a real problem, especially as the current inflation and the pressure on the financial balance of health systems do not offer any prospect of improvement. What is important to understand is that if we stop at this reading of things, at a form of temporary and circumstantial tiredness, we are not posing the problem properly and the solutions developed will necessarily be insufficient.

Measures intended to boost the medical worker by recognising the right to fatigue and perhaps granting some financial incentives would already be a good start. But it will not be enough. The problem is far deeper, more structural, and we must go further. We must dare to reexamine the societal and cultural representations of the reality of medical staff, which have gradually led to policies of under-investment in his or her well-being, or even in his or her safety.

What do you mean by policies of under-investment in the well-being and safety of the healthcare worker?

Do you know many professions in which you have to deal with sometimes grueling working conditions such as long or night shifts, undersized teams, an unsustainable staff/patient ratio, sometimes really abusive patients, a very rigid and legally framed division of roles, the responsibility for your actions that can be engaged at any moment because you have the well-being and sometimes the lives of people in your hands, a work culture that often does not allow you to share the burden of your fatigue or of the mistakes that you may have made? And yet, it is in this environment that we mistakenly think that medical staff will continue to find meaning in their work every day. As if the satisfaction of helping others was a reward that would get them through it all. As if their sense of dedication would immune them from any harm. How can we honestly imagine that physical and psychological insecurity, exhaustion, and even deep weariness will not follow? If need be, one only has to look at the statistics on the number of voluntary departures in hospitals to be convinced.

What do you propose as courses of action to deal with the problem in depth and to curb this weariness that you describe?

At ESNO, we have launched an online campaign ‘Don’t let them go’ focusing on specialist nurses, pointing out different elements on which a real societal evolution is needed: rethinking working conditions, respecting the right to rest or establishing a real work-life balance. But we need to go further and reach out to other medical professions throughout Europe. To do this, we need a coordinated approach, at national and European levels, which takes a comprehensive look at the conditions under which medical professionals can fulfil their potential and the support they need to invest in their careers. It takes scientific organisations and patient representatives working together to advocate for concrete changes in legislation or in hospital management policies. This is the dynamic that EUPSF would like to initiate at the Patient Safety Conference hosted by FOKUS Patient, by opening a dialogue with other potentially interested or supporting organisations.

What is actually the link between the well-being of the healthcare staff and patient safety?

Only cared-for healthcare professionals can effectively ensure safety and well-being of the patient. Results of my study**^1,2,3 about burnout in critical care nurses, published in several journals, showed higher results of emotional exhaustion (22.1%) as well as lower results of personal accomplishments (34.5%). And another study recently published in the British Medical Journal has just confirmed the obvious link with patient safety, finding that NHS doctors suffering from burnout are far more likely to be involved in incidents where patients’ safety is compromised. To care for the patient, let’s start by caring for the medical staff.

References

1. Friganović A, Selič P. Where to Look for a Remedy? Burnout Syndrome and its Associations with Coping and Job Satisfaction in Critical Care Nurses-A Cross-Sectional Study. Int J Environ Res Public Health. 2021 Apr 20;18(8):4390. doi: 10.3390/ijerph18084390. PMID: 33924271; PMCID: PMC8074906.
2. Friganović A, Selič P. Levels of Burnout Syndrome in Croatian Critical Care Nurses: A Cross-Sectional Study. Psychiatr Danub. 2020 Nov;32(Suppl 4):478-483. PMID: 33212452.
3. Friganović A, Kurtović B, Selič P. A Cross-sectional Multicentre Qualitative Study Exploring Attitudes and Burnout Knowledge in Intensive Care Nurses with Burnout. Zdr Varst. 2020 Dec 31;60(1):46-54. doi: 10.2478/sjph-2021-0008. PMID: 33488822; PMCID: PMC7780766.

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Patient involvement throughout their experience in healthcare is increasingly cited as a means of improving patient safety and quality of care. However, gaining patient trust, ensuring that objective information is available, and considering cultural diversity are some of the numerous challenges that need to be addressed. Organisations including the European Patient Safety Foundation (EUPSF) and FOKUS Patient (Sweden) are determined to take the discussion forward during the upcoming Patient Safety Conference and turn words into action.

Why is it important to take a closer look at patient involvement in the context of safety?

PG: The aim of both our organisations and the Patient Safety Conference is to improve patients’ wellbeing and safety throughout their medical journey, but we must realise that medical processes are too often designed and executed without considering patients’ possible fears, wishes and needs. To begin with, much progress still needs to be made to enhance patients’ knowledge of risks and benefits related to specific treatments, encourage them to speak up, be actively involved in the safety process, and ensure they understand the information concerning their rights. At the Patient Safety Conference we want to point out that, for the patient, not being included in the choices that concern him or her and not being well informed, can be a source of great discomfort.

MC: Beyond that, we are convinced that an appropriate involvement of the patient can, to some extent, contribute to the improvement of the patient’s own safety and quality of care, for example, through qualitative feedback or an adequate self-preparation for an exam or operation. Scientific studies have confirmed that patients are willing to participate, but this highly depends on the opportunities and on the quality of communication tools offered by the healthcare system itself. Patient involvement can be leveraged to improve patient safety but, at the same time, nothing will happen without dedicated effort.

What needs to be done to move things forward?

MC: The first thing to do is to make hospitals’ safety procedures more transparent and identify the critical interaction points between patient and practitioner all along the care pathways. It is also important to highlight the elements that the interactions should focus on, such as medical history, medication intake or physical activity level. Most of these elements have already been identified by researchers, they are well known and are being used in some hospitals. What is needed now is for healthcare institutions across Europe to acknowledge their importance and implement them systematically in their care pathways, with the appropriate tools, such as a structured interview or checklists to review.

PG: At the same time, we know that one patient is not the same as another and that, for example, gaining the trust of a patient in Sweden may not follow the same process as in Spain. We must take into account the different cultural context, which inevitably impacts the patient’s behaviour, and the practitioner’s too. We must therefore distance ourselves from a ‘one solution fits all’ approach and find the right words and tools, adapted to each context, that will convince all necessary participants of the importance of patient involvement. Professionals such as psychologists or sociologists clearly have a role to play here.

What do you intend to do to move things forward?

MC: We want to facilitate the debate, taking into account the specific context of each country, and amalgamate the views of different specialists concerning issues such as adequate communication or designing of tools. This is the idea of the Patient Safety Conference we are co-organising in Sweden this October, which will address global issues on patient safety and the specificities of the Swedish approach. Subsequently, as a European Foundation, we plan to bring these ideas to other countries through the Patient Safety Conference, especially those where the concepts of patient safety, and patient involvement, are struggling to emerge.

PG: Our aim is not to reinvent the wheel but encourage the exchange of knowledge and good practices between organisations so that we can make things happen on the ground. If you want to find out more, do not hesitate to join us at the Patient Safety Conference!

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