Suggested system-level hazards for health care
(First draft)
Introduction
In Sweden there is a proverb “don´t see the forest for all the trees (inte se skogen för alla träd)” which means being too absorbed by the details so that the big picture is not seen.
And that is what the concept of top hazards, or high-level system hazards, is about. There may be a very large number of hazards in a specific and defined system, but it is a good idea to define a few top or system level hazards comprising “all” other hazards in the system in question. As a start for a safety analysis, but also very much for understanding the big picture from a safety point of view, for educational purposes.
In this text, I will suggest a number of system-level or top hazards for health care, seen as a national system, hazards that may harm patients, by not getting the correct and needed health care. I also include how healthy persons may get harmed by health care. This is a first draft, my first suggestion but not the final one, and this may be done in several different ways, there is no single correct way to formulate this. My main reason for this text is educational purposes, but I hope to get some good feedback, regarding what top hazard(s) I have forgotten or which ones should be defined in a better way.
Definition of hazard, from Leveson, “Engineering a safer world”, chapter 7.2: “A system state or set of conditions that, together with a particular set of worst-case environmental conditions, will lead to an accident (loss).” Please refer to chapter 7 in Leveson´s book, for a deeper understanding of the fundamentals regarding hazards: https://direct.mit.edu/books/book/2908/chapter/78980/Fundamentals
Top hazards may also be defined for each subsystem, then they are top hazards according to that system boundary.
Example: Top or system level hazards for railway
First an example of system-level hazards from another high-risk field; railway. For railway signaling, for the traffic control of trains, there are two main top hazards:
A railway vehicle is located on a track where it might collide with other vehicles
A railway vehicle is running too fast
In order to prevent train vehicles to enter tracks in hazardous ways, there are safety systems called interlocking systems. These systems contain logics that prevent conflicting train movements at crossings and junctions, it prevents the possibility to set train routes in a way so that trains might collide by entering the same track or same part of a track.
If trains run too fast, derailment may occur, or it might not be possible to stop in time before a red signal. In order to prevent this, there are train control systems that brakes the train when needed, if the train driver does not for some reason.
But for a railway system with interlocking and train control systems, another top hazard may be added:
The availability of the signaling systems is too low
Availability is not safety, but if the availability of the safety systems is too low, these systems might be turned off and traffic control handled manually in order to keep traffic going. That is an important hazard. In that case, safety is handled with rules, as low maximum speed, but it is still a hazardous situation.
Suggested system level hazards for health care, on national system level
I will not go into detail about the system boundaries here, but the system is meant to refer to a whole national health care system. To do this more thoroughly, there is a need to define the boundaries to e g elderly care, infection control on national level, parts of the welfare system, security issues etc.
These hazards are chosen as events, not as conditions. Either could be used, but must be done consistently. For the railway example above, the hazards were defined as conditions.
My first draft of suggested system level hazards for a national health care system as a whole:
A patient that needs health care does not get it
A patient gets needed health care too late
A patient is diagnosed incorrectly
A patient is diagnosed correctly and in time, but is prescribed the wrong type of treatment
A patient is diagnosed correctly and in time, and correct treatment is prescribed, but it is given in an incorrect way
A patient gets treatment intended for someone else
A patient gets an infection when given health care
The state of seriousness of a patient´s state of health is misjudged
A healthy person undergoes some kind of intervention with side-effects, for other reasons than health problems, e g for beauty reasons, or donation of organs for transplants
A patient that is unable to work for a living, due to disease or injury, get further injured or more sick due to lack of money and/or lacking support from the society/state
A health care worker gets an infection or is injured or gets sick in some other way related to the work situation
Examples of different causes of the suggested system-level hazards
Below are examples, the lists of causes are not complete.
1) A patient that needs health care does not get it
There might be several causes to that hazard, below are some examples that in turn may have several causes, and so on. Often several causes are combined, there is seldom a single “root cause”.
The patient does not understand the need for health care and does not ask for it
The patient is scared for some reason and does not want to ask for health care
The patient is not able to ask for health care, and no one else helps the patient to do so
The patient can´t afford needed health care
The availability of health care is too low
2) A patient gets needed health care too late
Some examples of possible causes to this hazard:
The patient may be diagnosed correctly and in time, and prescribed correct treatment, but is not given treatment in time, e g due to low availability of surgery or medications
The patient does not understand the need for health care, and ask for it too late
The patient is scared for some reason and does not want to ask for health care
The patient is not able to ask for health care, and no one else helps the patient to do so in time
The patient can´t afford needed health care, which delays asking for it and/or delays being able to pay for it
The availability of health care is too low
The patient gets ill or injured far away from available health care
3) A patient is diagnosed incorrectly
Examples of causes that also could be defined as separate top hazards:
A patient that is ill, that has a disease or injury, gets an incorrect diagnosis
A patient that is ill, that has a disease or injury, does not get a diagnosis
A healthy patient gets a diagnosis in spite of being healthy (which may cause unnecessary treatment and/or interventions)
4) A patient is diagnosed correctly and in time, but is prescribed the wrong type of treatment
Examples of causes:
Lack of knowledge about what is correct treatment
Stressful working conditions
Human error
Inexperienced health care worker does not get the needed help and support, or does not ask for help
Guidelines are not updated according to available research
Guidelines are bad and/or erroneous
A cheaper but less purposeful treatment is chosen
5) A patient is diagnosed correctly and in time, and correct treatment is prescribed, but it is given in an incorrect way
Examples:
Lack of knowledge about and/or experience in how to give treatment and/or do interventions in a safe way
Stressful working conditions
Human error
Inexperienced health care worker does not get the needed help and support, or does not ask for help
Guidelines are not updated according to available research
Guidelines are bad and/or erroneous
6) A patient gets treatment intended for someone else
A patient may be mistaken for someone else, which in turn may have several different causes.
7) A patient gets an infection when given health care
Bacterial and viral infections, or infestations with e g lice or scabies.
8) The state of seriousness of a patient´s state of health is misjudged
This hazard could in many cases be a cause of #2 and #4 above. But it is also relevant for patients in the ICU and other patients during care at a hospital, and during surgery.
The following two specific hazards for palliative care are also relevant here:
A patient is incorrectly diagnosed as dying
A patient that is dying is not diagnosed as dying
In the first case, a patient may actually have a condition that may be treated, but is misjudged as dying and therefore gets palliative care instead of treatment. I believe this hazard is more often related to elderly patients, less often for e g cancer patients.
In the second case, a dying patient may get treatment that will do more harm than good, the patient may e g be sent to emergency care instead of getting a chance to die in peace at home, at a care home or hospice.
Both these are serious hazards related to the sometimes very difficult task to understand when a patient is beyond cure and treatment, and when a patient is dying.
9) A healthy person undergoes some kind of intervention with side-effects, for other reasons than health problems, e g for beauty reasons, or donation of organs for transplants
When treatment and interventions are given in health care, normally they are given because the risks are considered higher if not given. But for a healthy person, interventions will almost always cause higher risks, and therefore the safety is even more important.
10) A patient that is unable to work for a living, due to disease or injury, get further injured or more sick due to lack of money and/or lacking support from the society/state
This has more to do with welfare, but still, this is something that do harm some patients, that might e g cause suicides. Therefore, I include it for this top-level health care system analysis where some aspects of welfare may be seen as part of it.
11) A health care worker gets an infection or is injured or gets sick in some other way related to the work situation
For health care system safety, the workers are also part of the system. They might be sick and die from infections. They may also get ill due to bad working conditions.
Infection control in health care must regard hazards for all people involved, both patients and everybody working in health care.
In this text I have not included infection control in general, only as part of the health care system, but infection control for pandemics could be included as a part of a national health care system, as well as some parts of welfare.