Your Health, Our Priority: Strengthening Care Continuity and Human Performance for Safety

EQuiP Keynote Lecture from the 29^th WONCA Europe Conference
27.09.2024, 13:45-14:30, Auditorium
Lecture 1: Dorien Zwart, Lecture 2: María Pilar Astier-Peña,

Summary
The keynote presentation focuses on the critical importance of human factors to improve patient safety in primary healthcare.

Quality and Patient Safety emphasize the need to deliver healthcare correctly the first time, avoiding harm, ensuring patient satisfaction, and maintaining efficiency. However, the presentation acknowledges that as humans, healthcare professionals cannot completely eliminate errors.

Therefore, adverse events (AEs) are a significant issue in healthcare. In Hospital Setting: 8-12% of inpatients experience an AE, 50% of which are preventable. In Primary Care: 2% of patients suffer from AEs, with 80% being preventable. Common causes include medication errors, delayed test results, misidentification, poor interprofessional coordination, and administrative mistakes.

Several factors influence a quality and safe healthcare: 1) Patients’ Complexity: Multimorbidity, polypharmacy, and diagnostic challenges. 2) System Design: Infrastructure failures, outdated processes, and inadequate supervision. 3) Human Factors: Cognitive biases, emotional stress, and physical demands on healthcare workers. 4) Organizational Issues: Workload, undefined tasks, and poor procedural clarity.

Human factors encompass the cognitive, physical, and emotional behaviors of healthcare workers. It is crucial to highlight how stress, burnout, poor communication, and emotional distress (e.g., "second victim" experiences) can impair performance. Teams with clear communication protocols, such as the SBAR (Situation-Background-Assessment-Recommendation) framework, are better equipped to handle emergencies.

Effective teamwork is pivotal for patient safety. Defined tasks, standardized procedures, situational awareness, and robust escalation protocols are necessary to minimize risks.

Finally, it calls for a safety culture where organizations: 1) maintain safe work environments.2) Provide support for inexperienced or temporary staff.3) Empower leadership to foster a culture of safety.

Nevertheless it considers some strategies for mitigating risks addressing human factor challenges:
1) Education and training, focusing on communication skills, conflict resolution, and emotional resilience.
2) Enhancing IT infrastructure, creating standardized workflows, and providing ergonomic work environments.
3) Recognizing emotional distress, promoting well-being for healthcare professionals, and offering support for "second victims” of adverse events (professionals involved in adverse events who suffers emotionally afterwards).

The take home message with actionable insights are:

• Errors are inevitable but can be mitigated with human factors principles.
• Promoting teamwork, continuous education, and organizational support is crucial.
• Patient safety must remain a priority, with family medicine taking a leadership role in primary care safety.

This keynote underscores the need for a systems-based approach to reduce patient safety incidents while fostering a culture of resilience and continuous improvement in primary care.

The lecture presents a primary care clinical encounter involving an elderly patient, María, to highlight how poor communication and rushed decision-making can lead to a severe adverse event (a myocardial infarction). The case underscores the risks associated with workload, multitasking, and diagnostic errors in primary care which involved directly human factors as main contributing factors.

Eventually, a multiprofessional clinical encounter with the doctor and the nurse prevented the adverse event to happen in this situation. The case scenario serves as an example to highlight the relevance of the team as an important safety net to prevent errors from making harm to patients in primary care.