CMA PATIENT SAFETY POLICY FRAMEWORK (Update 2010)
The CMA’s mission is to promote the highest standard of health and health care for Canadians. This means, among other things, ensuring that the health care system is safe for patients and providers and effective in achieving good health outcomes for individuals and society. Unfortunately, studies published in recent years have raised concern that health care is not as safe as it could be; data collected by researchers in various countries has shown that there are unacceptably high levels of preventable adverse events, as high as 16% in one study of adverse events associated with hospital admissions. A study conducted by G. R. Baker, P.G. Norton et al, “The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada” showed an adverse event rate of 7.5 per 100 hospital admissions. (1) This suggests that of the nearly 2.5 million hospital admissions yearly in Canada, approximately 185,000 are associated with an adverse event and 70,000 of those possibly preventable.
These studies have focused attention on health care error and adverse events, but patient safety requires that participants in the health care system are constantly aware of the risks present in the system, and that risks are addressed proactively - preferably before an adverse event occurs. If a preventable adverse event does occur, it provides an opportunity to learn about and correct sources of error.
The CMA considers that a national patient safety strategy, aimed at building a culture of safety, is a priority. This Policy Framework has been developed to provide a clear statement of the CMA’s views on the principles that should underpin a patient safety strategy and to ensure clear support and direction for CMA members and staff involved in patient safety initiatives.
The Health Care System
Errors and adverse events are inevitable in any complex system and more complex systems are more prone to errors. Nevertheless, studies have demonstrated an unacceptably high level of preventable adverse events associated with management of health care.
1. Patient safety initiatives should aim to improve health outcomes for patients by minimizing the rate of preventable adverse events and improving the management of events when they occur.
2. Patient safety is one aspect of quality health care; activities relating to patient safety should result in a net increase in the quality of health care.
3. Patient safety initiatives should recognize that error and adverse events occur because of qualities of the system within which individuals operate. A primary concern of initiatives should be to prevent future errors by addressing the system rather than blaming and punishing individuals.
The Canadian public has a reasonable expectation that health care will not result in avoidable injury.
4. Patient safety initiatives should support the accountability of the health sector, including providers, funders and regulators, to patients and the wider public for the safety of health care.
Participants in Health Care
Patients as partners
5. Patient safety initiatives should promote the role of patients as partners in the provision of safe care, including the prevention and management of adverse events.
6. Patient safety initiatives should encourage and anticipate the full and appropriate disclosure to patients of relevant information that is material to their health and healthcare, including information about adverse events or effects.
Professional responsibility and support
With a very few exceptions, health care is delivered by competent, caring professionals who are striving to achieve a good outcome for patients.
7. Patient safety initiatives should recognize the responsibility of professionals for achieving and maintaining the standard of their own practice.
8. Patient safety initiatives, while responding appropriately to adverse events, should be sensitive to the professional role and personal well being of individual physicians and other health care providers.
Learning and Collaboration
9. Patient safety initiatives should promote and reflect teamwork, communication and collaboration at all levels.
10. Patient safety initiatives should support learning from one’s own experience and the sharing of knowledge so that it is possible to learn from the experience of others.
Legal and Regulatory Environment
11. Patient Safety initiatives should promote a legal and regulatory environment that supports open communication and effective management of adverse events.
12. The protection afforded to the opinions expressed within quality assurance committees must be upheld
Evidence Base and Evaluation
Patient safety initiatives should be based on sound evidence.
Patient safety initiatives should contain provision for appropriate evaluation.
Patient safety initiatives should contain provision for broad dissemination of findings.
PATIENT SAFETY INITIATIVE AREAS
Building a culture of safety in Canadian health care will require the collaboration of many different groups and organizations. The CMA can play a leadership role within this larger group and within its own constituency of over 70,000 physicians. In some instances, it will be the CMA’s role to advocate for initiatives that can be delivered only by another provider or through a consortium; in other instances, CMA can assume sole responsibility for taking action. The CMA has identified that, as priorities, it will support:
Advocacy for changes to legislation and regulation that would remove disincentives for health care providers to share information about adverse events.
Raising awareness of patient safety and changing attitudes towards risk, error and adverse events within the health care community.
Developing and providing resources such as clinical practice guidelines and information technology systems that have been shown to standardize practice and reduce adverse events.
Reporting systems that collect and aggregate data on risks so that good practices can be developed and shared.
Education and training for health care professionals and managers to provide them with the conceptual and practical tools to introduce change into their practice and organizations.
Advocacy for, and development of, an agenda for patient safety research in Canada.
The involvement of government at all levels in supporting and committing resources to initiatives for improved patient safety.
Adverse event – any unintended injury or complication that is caused by health care management rather than the patient’s disease and that leads to prolonged hospital stay, morbidity or mortality. Adverse events do not necessarily result from error, for example a toxic reaction to a drug in a patient without apparent risk factors for the reaction.
Error – the failure of a planned action to be completed as intended (“error of execution”) or the use of a wrong plan to achieve an aim (“error of planning”). An error may not result in an adverse event if the error does not result in harm or is intercepted.
Risk – the chance of injury or loss as defined as a measure of the probability and severity of an adverse effect to health, property, the environment or other things of value.
(1) G. Ross Baker, Peter G. Norton, Virginia Flintoft, Régis Blais, Adalsteinn Brown, Jafna Cox, Ed Etchells, William A. Ghali, Philip Hébert, Sumit R. Majumdar, Maeve O'Beirne, Luz Palacios-Derflingher, Robert J. Reid, Sam Sheps, and Robyn Tamblyn. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada Can. Med. Assoc. J., May 2004; 170: 1678 - 1686.
CMA Statement on Emerging Therapies
The CMA is keenly aware of the heart-rending suffering experienced by MS patients and the devastating impact it has on families and we recognize how desperately they are seeking treatments to alleviate their symptoms. Physicians and researchers dedicate their lives to finding new treatments to prevent and ease the suffering of patients while supporting those battling disease. Along with the physician's care and compassion, clinical research is a key weapon in the battle to manage and treat disease. The CMA believes that all medical decisions must be based upon scientific evidence. That is at the heart of our commitment to patient-centred care.
The CMA is committed to the principle that, before any new treatment is adopted and applied by the medical profession, it must first be rigorously tested and recognized as evidence-based. This principle is highly relevant in the case of the Canadian Institutes of Health Research (CIHR) recent recommendations. The CMA concurs with the CIHR's position on the need for an evidence-based approach to the development of clinical trials of the recently proposed condition called "chronic cerebrospinal venous insufficiency" (CCSVI). We would hope that the findings of the seven diagnostic studies that are underway will be shared and analyzed as soon as they become available, and that clinical intervention trials would be supported as indicated by the evidence and if researchers come forward with scientifically sound ethical protocols. If additional Canadian funding bodies initiate clinical research in the area, we would encourage CIHR to provide advice if requested.
Obesity and Cardiovascular Disease (Update 2004) (Applicable to Canadians aged 20-60 years)
Obesity is a chronic condition that is multi-factorial in origin, complex to treat, and is a major contributor to heart disease, type II diabetes, hypertension, stroke and some cancers. Due to the magnitude of the impact that obesity has on heart disease and stroke, and to the clustering of risk factors for cardiovascular disease that are often found in the obese patient, obesity is recognized as a major risk factor for cardiovascular disease.
The impact of obesity points to the importance of prevention through healthy behaviours including increased physical activity and a healthy nutritional diet beginning early in life, and continuing through all stages of life. Solutions require comprehensive approaches that are both education and environment based, and that target and assist individuals, the family, and communities to engage in healthy lifestyle patterns and behaviours. Solutions also require ongoing research to develop and evaluate comprehensive approaches to obesity prevention, management and treatment, and surveillance data that measures and tracks obesity and its impact in Canada.
The World Health Organization defines obesity as a condition of excessive body fat accumulation to an extent that health may be compromised.
Body Mass Index (BMI) is a widely accepted parameter used to distinguish between obese and non-obese adults aged 20 to 60 years and thus provides information about the subsequent risk of cardiovascular disease.
BMI is calculated by dividing the weight (in kilograms) by the square of the height (in metres).
BMI = weight (in kilograms)
height (in metres) * height (in metres)
A BMI equal to or greater than 30 kg/m2 is classified as obese, while a BMI in the range of 25 to 29.9 kg/m2 is classified as overweight.
Waist circumference (WC) provides an independent prediction of health risks over and above BMI. Increased waist (abdominal) circumference is associated with increased risk of cardiovascular disease, dyslipidemia, type II diabetes and hypertension. As waist circumference increases above 102 cm for men and 88 cm for women, the risks of health-related illnesses increase.
Populations at Increased Risk
Obese individuals with diabetes, hypertension, or dyslipidemias or who are physically inactive are at increased risk of cardiovascular disease, compared to individuals without these conditions.
A BMI between 25 and 29.9 kg/m2 (overweight) is associated with elevated risk of cardiovascular disease, type 2 diabetes, hypertension and dyslipidemia.
Weight gain during young adult life may be one of the most important determinants of future development of cardiovascular risk factors and cardiovascular disease. Adults who gain weight have increased risk of coronary heart disease compared to those with stable weight. Weight gain during adult life may contribute to future development of ischemic heart disease regardless of initial body weight (obese or non-obese).
Canadians of Aboriginal, Chinese, and South Asian (from India, Pakistan, Bangladesh, and Sri Lanka) descent have higher rates of obesity-related chronic diseases (for example diabetes, hypertension and cardiovascular disease).
Individuals with lower socio-economic status have higher rates of obesity than those with higher socio-economic status.
Promotion of Healthy Weights
In April 2002, the Public Health Approaches to the Prevention of Obesity (PHAPO) Working Group of the International Obesity Task Force (IOTF) identified that a comprehensive approach to obesity prevention should:
Address both dietary habits and physical activity patterns of the population
Address both societal and individual level factors
Address both immediate and distant causes
Have multiple focal points and levels of intervention (i.e. at national, regional, community and individual levels);
Include both policies and programs; and
Build links between sectors that may otherwise be viewed as independent.
Research is needed to:
Develop a standard definition and a standard measurement technique for determining obesity in children.
Develop obesity measures for older, ethnic and gender specific populations.
Identify and develop effective primary prevention methods for individuals, families and communities to reduce the prevalence of obesity in all stages of life.
Improve awareness and knowledge about the health effects of obesity and healthy living.
Develop effective primary prevention measures and strategies that are therapeutic, secondary and tertiary in nature.
Identify and track rates of obesity and overweight in Canada.
Assess the effectiveness of obesity prevention and treatment initiatives.
Identify and implement the most effective primary prevention strategies for ethnic populations.
Develop and implement effective healthy public policy for the prevention, treatment, and management of obesity.
Further, the surveillance of obese and overweight Canadians is necessary in order to assess the effectiveness of prevention and treatment initiatives. It is only through the combined action and resources of governments, non-governmental organizations, non-profit and private sectors to develop and implement a comprehensive approach to curb the growing trend of obesity in Canada.