Gunther P (2023) Prioritising Patient Safety and Combatting Fatigue in Healthcare. HealthManagement.org The Journal. 23(6):414-417.

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Prof. Reinhard Strametz holds the chair for patient safety at RheinMain University in Wiesbaden/Germany. Before that, he worked as an anesthesiologist at Frankfurt University Hospital and was Chief Quality Officer of this hospital. For over than twenty years, as both a doctor and an economist, he has been interested in aspects of quality and clinical risk management and today has the honor of heading the Wiesbaden Institute for Healthcare Economics and Patient Safety (WiHelP).

Why does Patient Safety and, more specifically, the topic “Leadership, team and organisational performance” personally matter to you?

Over the last two decades, we have learned a lot about tools for mitigating clinical risks, especially in hospital care. But sometimes these tools work well in one place and fail miserably in many others. The main reason for this is not the way in which they have been used, but because some medical facilities do not have a sufficient safety culture. In addition, secure communication and sufficient team performance will play a key role in the successful implementation of patient safety measures. But what is the basis for this to happen?

Initially, we talked about the “error culture” that needed to be improved, but today we focus more on concepts of High-Reliability Organisations and Safety Culture. The latter can be seen as the goal of our efforts, but to some extent it is also a prerequisite for the success of our efforts, the fertilizer, so to speak, for the still tender seedling of patient safety in many organisations.

And who will create the culture? Whose responsibility is it to ensure that an appropriate safety culture takes root in facilities? That’s right, it’s the job of the leaders. It’s one of the most important and noblest duties of healthcare leaders. 

What exactly is “second victim support”? Do you know of any examples of such support systems in the field? What is your experience in this area?

A Second Victim can be defined as any health care worker who is directly or indirectly involved in an unanticipated adverse patient event, an unintentional healthcare error, or a patient injury and who becomes a victim in the sense that he or she also suffers negative consequences.

This is a genuine human reaction and evidence shows that the majority of health care workers are already second victims. The problem with this human reaction is that, without proper support, it will lead to dysfunctional coping strategies like self-stigmatisation, loss of self-confidence, substance abuse or the practice of defensive medicine. Worse still, those affected might develop serious mental health conditions such as post-traumatic stress disorder (PTSD) or depression. This is a serious hazard to health worker safety but also to patient safety as the likelihood of making (additional) mistakes increases dramatically. Without sufficient and timely support, this can become a vicious circle.

On the other hand, we know that particularly early support during the experience of the second victim phenomenon is very likely to lead to complete recovery or even fulfilment. We have to acknowledge that the treatment of PTSD is very effective, but only at an early stage of this condition. As the second victim phenomenon is clearly linked to occupational circumstances and therefore consitutes an occupational hazard, programs to support second victims should be implemented as part of health promotion and prevention programs in. the workplace in any healthcare institution.

There are a few flagship projects in Europe, such as KoHi in Vienna/Austria, MISE in Spain or PSU-Helpline in Germany, but we are still miles away from a comprehensive solution in all healthcare institutions in Europe, such as the one already implemented for needle-stick injuries, for example.

Is this an easy subject to tackle in the field? Doesn’t it run against the culture of the super-carer, who deals with every situation?

That is a very valid point. During our research, we identified three major barriers to overcome, which lie within ourselves. 

Firstly, we are trained to be the healthiest, to be heroic and to cope with every situation. But sooner or later we will find out that beyond sleep deprivation, loss of social contacts outside our healthcare institution and, of course a considerable amount of resilience, we  remain human beings with natural limits. 

To overcome these inhibitions, the peer support by colleagues has proved very effective. It would be more difficult to admit, as a “bulletproof” doctor, that I need the help from a psychologist. Another advantage is that my colleague also knows my situation very well and probably may have experienced a similar one him- or herself.

The second barrier is related to our training to be confident and to show confidence to our patients. The risk of being overconfident is inherent. We hypothesised that a significant proportion of medical doctors and nurses who are overconfident in their ability to adapt would underestimate the risk of becoming second victims and, unfortunately, we were able to confirm this.A third barrier is also related to our socialisation. When asked about their knowledge on the Second Victim Phenomenon before assessing their own symptom load, only a minority of doctors and nurses had ever heard of it, which may explain the self-stigma, which can also be seen as a potential barrier to accepting help, as they might feel they do not deserve support. This phenomenon and evidence-based ways to prevent or mitigate its potential effects should therefore be taught as part of our basic medical education.

What are the advantages of such support systems?

Besides acute care provided to second victims, implementing such programs will also increase the psychological safety of staff, which is a cornerstone of effective teamwork and mitigation of clinical risks.

Implementing such programs is therefore a triple win: Firstly, healthcare workers will benefit from increased psychological safety as well as sufficient primary and secondary prevention. Secondly, our patients will benefit from a reduced risk of errors leading to harmful preventable adverse events, which, according to numerous OECD reports, will also save huge amounts of money. Thirdly, the healthcare organisation will benefit from reduced staff turnover, which in our economic simulations also pays off very well.

Implementing such programs should therefore be considered as a no-brainer as they can improve the  quality of care while reducing costs, with a high return on investment. 

What are the key points to bear in mind when implementing them?

Support programs, like any implementation in healthcare, need to be evidence-based, contextualised and facilitated, for example by honest communication about the issue and explicit leadership. If our role-models admit that this is a serious problem that sooner or later will affect everyone in the business, they will be able to overcome the taboo, that still exists in many institutions. 

Successful programs will include both peer support of trained and sensitized colleagues and professional support that will be available in a timely manner. But apart from treatment of second victims, those programs should start before in creating psychological safety by creating a safety culture in which self-care is not regarded as selfishness but as an expression of professionalism.

We should always remember what is said in the World Medical Association Declaration of Geneva: “I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard… I MAKE THESE PROMISES solemnly, freely, and upon my honour”

Do you see a link between the widespread implementation of support programs and any general issues or crises that could affect healthcare systems and patient safety?

The greatest challenge facing healthcare systems around the world is maintaining their capacity in terms of staff. We are in the midst of a huge staffing crisis, seeing many trained healthcare workers to either leave their countries to make up for shortages elsewhere or to even drop out of the healthcare system.

By creating a culture of safety and support, we can fight this crisis, which will otherwise lead to the collapse of healthcare systems in the near future. It is not about bringing more and more people into our healthcare systems and burning them out, but about keeping those who are already in the system healthy and safe. Because if we don´t care for them now, they won´t care for us in the future. 

Prof. Dr. Reinhard Strametz
Wiesbaden Institute for Healthcare Economics and Patient Safety (Germany)
LEADERSHIP, TEAM AND ORGANIZATIONAL PERFORMANCE  
Why and how to design a safety-oriented organization?  

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Andrea Rappagliosi is currently Senior Vice-President Public Affairs EMEA, Canada and LATAM at Edwards Lifesciences, after holding various international positions in the healthcare industry. In 2022, Andrea joined the European Patient Safety Foundation as a Board Member. 

Edwards Lifesciences has supported the Fighting Fatigue Together campaign since the very beginning. Why is this campaign important to you?

Patient safety is our foremost priority, driven by our mission  of transforming patients life by  enhancing patient outcomes. Health worker safety and patient safety are intrinsically interconnected. Human factors, such as fatigue, poor working conditions and staff shortages, can culminate in diminished patient satisfaction, compromised care quality, medical errors, and substantial costs for both caregivers and healthcare systems. Hence, ensuring the well-being of healthcare workers is imperative to achieving safe and favourable patient outcomes. This can be only achieved by combining the fast adoption of technological innovation with the setting of innovative integrated process from diagnosis to treatment and cure, able to transform and elevate the standard of care by reducing the burden on healthcare workers and healthcare system at large.

The increasing workload and the shortage of staff that hit Europe over the past few years have led to an extremely high and worrying level of fatigue among healthcare workers in Europe. The largest German health insurance association AOK, has found among its insured members that, sickness related to burnout among carers caused an average of 28.2 days of incapacity for work per 100 AOK members – almost twice more than in other professions with 14.2 days^[1]! In the Netherlands a recent study shows that with the ageing of the population and the rise in chronic disease, the demand in healthcare will keep growing and by 2040, 1 out of 4 workers will have to be a healthcare worker in order to meet the demand^[2]. This is concerning when we know that 40% of medical doctors are close to retirement age in one third of countries in Europe^[3]. As indicated by WHO Europe we are facing a ticking bomb: the healthcare workforce crisis.

The Fighting Fatigue Together campaign is critical to raise awareness of the state of fatigue among healthcare workers and its impact on patient safety and outcomes. This campaign is the first of its kind in Europe. 

I strongly believe EUPSF can play a pivotal role in coordinating this pan-European effort to enhance patient safety and outcomes in Europe. It is crucial to have more industry members, hospital providers, patient safety stakeholders and policy makers joining forces and supporting the campaign. Only by working together can we tackle healthcare workers fatigue, improve patient safety and outcomes, and build the resilience of healthcare systems in Europe.

New technologies open new prospects for improving patient outcomes and safety. But, on the other hand, they require healthcare workers to adapt their knowledge and practices up to date and to be ever more responsive. What could be done to ensure that medical innovation actually achieves its objective and doesn’t become just another source of fatigue?

In this current environment, all stakeholders have a role to play in improving patient safety and outcomes. 

First, the industry has the responsibility to develop innovations at the service of patients, health professionals, but also supporting the efficiency and sustainability of our healthcare system. Innovation is no longer an option, but a necessity to meet the challenges of our health system and initiate a real transformation under the 4 Ps framework: for a more preventive, predictive, personalised, participatory and evidence-based medicine. 

Second, healthcare systems are not currently designed to embrace these innovations and exploit their full potential. They need to urgently prioritise and accelerate the adoption of these innovative technologies or processes which increase hospital efficiencies, optimise hospitals capacity and improve quality of care, therefore reducing the burden on healthcare workers. 

Third, patients should be better informed and empowered in their treatment journey. They should have the right to be consulted and participate in the decision making in all aspects of their treatment to ensure the best outcomes. Well informed and motivated patients can have a significant impact on their own safety.

But couldn’t the industries, which are less caught up in the continuous flow of care to be provided, step in and make things easier for the hospitals?

The industry certainly has a role to play in developing innovations and designing processes leading to hospital efficiencies and resources optimisation. Innovations, such as digital technologies for predictive medicines based on AI-derived algorithms or technologies and devices which make minimally invasive procedures feasible, have showcased their potential to yield significant advantages for patients in terms of clinical outcomes and resource efficiency. Additionally, they can allow automating tasks, offer decision support, reduce hospital length of stay, ultimately reducing the pressure on healthcare systems.

Mr. Andrea Rappagliosi
Edwards Lifesciences (Switzerland)
WELLBEING AND SAFETY OF THE HEALTHCARE WORKERS
Panel discussion, “Fighting Fatigue Together – Collaborating across Europe”

^[1] AOK-Studie: Erhöhtes Risiko für Burn-out bei Pflegekräften (aerztezeitung.de), 2022

^[2] Gupta – Prevent the next wave – Why labour-saving innovations are needed in healthcare and how an innovative ecosystem enables progression

^[3] Ticking timebomb: Without immediate action, health and care workforce gaps in the European Region could spell disaster (who.int)

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As representatives of the European Patient Safety Foundation, the authors wish to share with the wider patient safety community some current perspectives from across Europe. As the title suggests, in their view, the healthcare systems are dominated by the reality of having to deal with what are seen as multiple crises at the same time, and somehow keep patient safety on the agenda and come up with strategies and initiatives to make improvements. The situation is made even more complex by the fact that these crises take an additional toll on those responsible for delivering safe care, healthcare staff themselves, who already have to cope with difficult working conditions in normal times.

We are thankful to the Editorial Board of the Journal of Patient Safety and Risk Management for an excellent collaboration and support with promotion of our conference.

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Dr. Irene Grossmann works at the Delft University of Technology (Netherlands), as assistant professor at the  Centre for Safety in Healthcare at the Delft University of Technology. She is co-founder and co-lead of the Institute for Health Systems Science at the same university. Besides her academic work she holds a clinical position as a surgeon, previously working as a surgical oncologist and on the intensive care, currently working part-time at the Emergency Care Department.

Why does patient safety matter to you? 

For me, patient safety is an integral part of my professional responsibility. During my career, both in research and in clinical practice, I have encountered several situations that have left me wondering whether we do the right things and do things right. These situations made me raise questions. For example, I designed and collected data in a prospective database of colorectal cancer patients. As we needed an unselected cohort, we included all patients within a specific time frame (2007-2011). My data turned out to be rather different from those in the literature, in terms of patient characteristics and outcomes. One of our observations was an unexpectedly high mortality of patients undergoing right hemicolectomy. When I raised this issue, I was met, next to recognition, also with resistance and denial. I was repeatedly told: “That doesn’t happen in our hospital”. Our local results were later found to be the same as the national results. So, why the resistance? For us it was just a sign that we needed to look at the causes, but that feeling was clearly not always shared.

Why are you focusing, in your work, on the question of the implementation?

Because there is a huge gap between the knowledge and know-how already available, and what is known and applied in the medical domain. When I started in my position at the TU Delft two years ago, I obviously had some ideas, since I had applied for the position, but honestly, I had no clue yet how extensive the knowledge in safety sciences was. It just does not reach healthcare somehow. After a year or so, I also realised that there is no need to develop anything new in the areas of change management, quality improvement strategies or the creation of learning organisations, as it is already all there. Instead, we need an idea how to propel this knowledge into the health and care sector. I chose to focus on what medical professionals need to embrace knowledge that they are mostly unfamiliar with, such as engineering – and systems science.

How can we achieve results in terms of patient safety, especially in times of crisis?

Well, our vision is that especially in times of crisis safety should be addressed. Safety is an outcome of well-functioning systems; the better the systems function, the lower the waste and the higher the quality and safety. This is not just a theory; it has been proven in other domains and it is a key statement from both the OECD and the WHO. It requires leadership and, in my professional opinion, a systems perspective to understand the mechanisms of failure and the changes that are needed to address these. Quality improvement also is a continuous and never-ending process. Projects on safety in healthcare are often not imbedded in the organisation but merely temporary add-ons. To achieve sustained safety improvements, safety must be part of the daily routine, infrastructure and, ultimately, workplace culture. This can be done, but it must be a priority. Safety is not just a task for individual healthcare professionals to signal and resolve; for a large part, safety can be organised. This means that the leadership must take responsibility for doing precisely that.

Dr. Irene Grossmann
TU Delft Centre for Safety in Healthcare (The Netherlands)
CHALLENGES OF IMPLEMENTATION
Tools and recommendations for implementing patient safety practices

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Why does the wellbeing and safety of the healthcare workers personally matter to you?

The more I worked with trainees and in different multi-professional clinical teams, the more I realised that we deliver better care to patients when our workload is realistic, and people feel respected and valued as individuals. If the staff are looked after, they deliver safer and kinder service to patients.  

In recent years, as the complexity of patient care has increased, and patients have rightly expected higher standards of care, more interest has been paid to the importance of the wellbeing of healthcare staff.  We all want to be cared for by people who enjoy their jobs, who work in good teams and who have the resources to deliver the best care.

At a certain point in your career, you decided to take up the fight against healthcare professional fatigue. Why?

Over time, I began to see more and more signs that the level of fatigue among the medical staff was increasing in a worrying way. And in 2017, the untimely death of a trainee in a car accident driving home tired after a night shift convinced me we needed to take action to address staff fatigue. 

Together with a group of trainees and consultants and with the support of the Association of Anaesthetists, Royal College of Anaesthetists and Faculty of Intensive Care Medicine in the UK, we established a joint working group on fatigue.  We organised a survey and found that 57% of trainees and 45% of consultants had had an accident or a near miss driving home tired, and many had no rest facilities at work. We clearly had a problem.

As a medical professional, how would you describe your experience with fatigue?

When I was a trainee, fatigue was regarded as an occupational hazard; we were expected to cope and working long hours was regarded as a badge of honour.  We had almost no understanding of why we need to sleep and the impacts of sleep deprivation on us and on our clinical performance.  However, we did have on call rooms and rest facilities.  

Over the last 30 years, working hours have been cut by half as doctors expected a better work-life balance.  But work has become more complex, more stressful and patients rightly expect more involvement in their treatment.  Many trainee doctors work 12-hour night shifts and no longer have an on call room to sleep in.

From a professional point of view, this is obviously problematic, as fatigue affects how we think and behave in ways we may not notice; how we assess risk, make decisions, perform complex tasks, interact with colleagues, and manage our emotions. Attention, memory, response times, vigilance, hand-eye coordination, arithmetic ability and impulsivity are all affected.  

In a few words, what will you be focusing on at the conference?

I would like to explain what we’ve been able to do in the UK to try and change the approach to fatigue – both culturally and practically – in hospitals and at a political level, with the aim of making it easier for people who are interested in the problem to take action elsewhere in Europe.

Because I believe that the fatigue of healthcare professionals knows no borders. In many European countries, there are shortages of many healthcare professionals: nurses, doctors, radiographers, pharmacists, etc. Patient demand is increasing with an older, less healthy population, so healthcare professionals do their best to keep the service going, working harder to cover gaps. Naturally this takes its toll and people end up getting used to chronically shorter sleep and don’t recognise its impact on their wellbeing. Where people work in challenging and unsupportive environments, this can even lead to burnout. Much needs to be done, and I think that a European network such as the Fighting Fatigue Together, which I have joined, can help to tackle this issue more effectively across Europe. 

Finally, I’d like to open the discussion to what I consider to be an essential topic: the management of fatigue as a risk in the medical sector. All other safety-critical sectors are required by law to manage staff fatigue effectively as part of their overall safety structures. Healthcare workers have the same physiology as airline pilots and nuclear workers, so the medical sector should have the same regulatory framework. Good fatigue risk management could improve staff and patient safety, staff morale and staff retention.

Dr Nancy Redfern
EUPSF Advisory Board Member
Co-chair of the Joint Fatigue Group (UK)
WELL-BEING AND SAFETY OF THE HEALTHCARE WORKERS
Fighting Fatigue Together – Collaborating across Europe

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She holds a Diploma in Critical Care Nursing from Queensland University of Technology, Brisbane, Australia, and a PhD in Patient Safety from the University of Bergen, Norway.

Why does Patient Safety and, more specifically, the topic “Patient involvement” personally matter to you? 

Involving patients in their own safety is essential to better prevent harm to patients in healthcare, and I think we need to go further today, with more innovative and targeted patient involvement initiatives. Sometimes we don’t realise how powerful this involvement can be, in terms of changing working practices and improving the quality of care.

As an example, I’ll take the tool I’m currently working on, which are safety checklists specific to surgical patients. In fact, the idea came from a patient representative. After listening to a presentation by Professor Arvid Steinar Haugen on surgical safety checklists in 2012, he asked the following question: “What about us, the patients? Don’t we need a surgical safety checklist too»? So in 2016, the work on such a checklist began in our hospital and, right now, we are conducting a clinical trial on the effect and implementation of such a checklist.

What are exactly patient-owned checklists? What can be said about their impact?

The Surgical Patients own Safety Checklist (PASC) is designed to systemize the most crucial patient information before surgery and at discharge from hospital. It helps patients to be more aware of what actions they can take to prepare for surgery and which information they need throughout the surgical pathway. 

Preliminary results from our ongoing clinical trial on the impact and implementation of the PASC are positive from the perspective of both patients and healthcare professionals. Patients indicate that the PASC helps them better control important information and encourages them to ask questions when information is unclear or missing. For their part, healthcare professionals indicate that surgical patients who use the checklist are better informed and more involved in their safety throughout the surgical process.

Don’t you think this kind of tool can lead to tensions, with healthcare professionals feeling under the surveillance of patients? Or to a shift in responsibility for the quality of care from the healthcare professional to the patient?

It is important to specify that the PASC is developed with patients, patient representatives and an interdisciplinary healthcare team, with the aim of meeting the needs of each party.

So far, we have not experienced any negativity from healthcare professionals regarding the use of PASC. And after talking to the patients regarding the issue of the responsibility, they say that they rather receive the checklist than not, and that it makes them feel more in control of their own situation. 

What else are you going to tell at the conference?

I’d like to detail the key elements in the implementation of the PASC, so that it can be reused in other countries and healthcare settings because the benefits with the PASC are many.

For example, we all know that there is a constant shortage of healthcare professionals, which has a major impact on patient safety. Healthcare professionals are overworked, fatigued and under constant pressure to perform ever more tasks or procedures. The use of patient-specific checklists cannot solve this problem, but it can act as a systemic barrier that allows patients to prepare for surgery and request clarification or missing information.

Dr Kristin Harris
University Hospital, Bergen, Norway
PATIENT INVOLVEMENT SESSION
Surgical Patients’ owned Safety Checklist (PASC), best practice example from Norway

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