The Canadian Patient Safety Institute has recently launched the Global Patient Safety Alerts online database. This is a free information-sharing patient safety resource which will act as a centralised repository of safety alerts from 22 contributing organisations around the world (including the National Patient Safety Agency and the National Reporting and Learning Service from England and Wales) and which aims to “prevent and mitigate patient safety incidents”.
While “no-one goes to work in the morning to harm people” harm still occurs and lessons can and should be learned from these incidents, and shared as widely as possible. Learning works well locally but sharing information within the same country, let alone the world, has been a challenge that the database seeks to address.
The database was developed in response to an investigation undertaken by the Canadian Patient Safety Institute (CPSI) into what was needed by the global patient safety community and what patients and families wanted to happen as a consequence of their experiences of harm.
Healthcare providers want a repository to capture lessons learned and to make it easier to do so (healthcare systems around the world are at full capacity and keen to avoid further burdens). Patients want to be told the truth and to receive an apology but they also want assurance that their experience will go some way towards preventing others from suffering the same problems. This database can significantly contribute to that by providing frontline healthcare providers with access to patient safety alerts, and their causes and recommendations.
The database was unveiled on 15 February 2011 and you can watch the launch webcast here with speeches in person (or by conference call) from Hugh Macleod (CEO, Patient Safety Institute), Paula Beard (Director of Operations, Canadian Patient Safety Institute), Kaaren Neufeld (Chief Quality Officer at the Winnipeg Regional Health Authority) and Sir Liam Donaldson (Chair of WHO Patient Safety, World Health Organisation). Currently the database shepherds together 167 patient safety alerts (in French and English) that already exist in the public domain and another 700 will be added over the coming months.
Each of these alerts has had patient-identifying details removed while the overall context of the patient story behind it remains making these a meaningful tool for learning. With the database providing a cohort of case studies there is an opportunity to draw some conclusions about similarities among cases that may not otherwise be as quickly picked up. This emphasises that “reporting can lead to learning” – lessons learned from errors in care in one place can be translated into benefits in another part of the world.
In his speech Sir Liam Donaldson used the metaphor of the ‘orange wire test’. During a routine aircraft engine check, if an engineer notes that an orange wire, which is needed for the proper functioning of the engine, isn’t properly connected then he or she will connect it correctly. Crucially, they will also share this information with other engineers so that aircraft elsewhere can be checked to ensure that those engines don’t share the same problem. Sir Liam believes that this database will make an important contribution in bringing healthcare systems around the world closer to ‘passing the orange wire test’.
In March and April 2011 there will be (free) web-based training sessions in using the database.
- When will health care pass the orange-wire test?
- About the National Reporting and Learning Service
- About CHI+MED (Computer-Human Interaction for Medical Devices)