Patient safety database goes online

A Canadian-developed, Web-based patient safety alert database has been launched to collate information about harmful incidents from around the world in hopes it will spur reforms to prevent similar incidents in the future.

The publicly accessible site, Global Patient Safety Alerts, will contain summaries and links to more than 900 recent patient safety advisories, alerts and recommendations on incidents in which a patient was harmed, or had the potential to be harmed, from some 22 international, national and regional health authorities and organizations worldwide (www.globalpatientsafetyalerts.com).

The Canadian Patient Safety Institute (CPSI) developed the site to give health care providers and policy-makers an opportunity to become aware of adverse events, identify similarities and patterns in sources of risk, share solutions and ultimately, prevent similar ones from occurring in the future.

“It’s transparency gone wild,” says institute CEO Hugh MacLeod. “The reality is we’re working in very complex, fast-moving systems. We have new drugs, new technologies, but also new demands and expectations from the public, and mistakes happen. Now, however, we can begin to share, analyze and learn from those mistakes on a broader scale.”

“It’s transparency gone wild,” says Canadian Patient Safety Institute CEO Hugh MacLeod.

Image courtesy of Canadian Patient Safety Institute

Historically, when an incident occurred in one jurisdiction, other regions were not made aware of the mistake, and did not benefit from the lessons learned, because no global system existed to gather and share the information, says Paula Beard, CPSI director of operations, citing recent oxygen tube mix-ups as an example. “Incidents were happening on a one-off basis in hospitals across Canada. What we’ve now found out through our system is that they were also happening around the world and a number of solutions had been implemented, but there wasn’t any coordination between the organizations that were trying to solve that problem.”

The website aggregates data from groups that produce 80% to 85% of global patient safety information, including the health authorities and incident reporting systems of the European Union, United Kingdom, Australia and a number of American states. It also collates patient safety alerts from organizations such as the Institute for Safe Medication Practices Canada and the UK-based National Patient Safety Agency.

CPSI creates summaries of all the information it gathers to allow “time-pressed” users to readily assess whether it’s something they “want to spend more time on, or is this a little off point and I want to keep looking,” says Beard. The summaries, which are reviewed for clinical accuracy, are also translated into World Health Organization (WHO)-approved nomenclature so that users can easily “compare apples with apples.”

Recommendations and proposed solutions to patient safety problems are posted in their own section on the database for ease of access, she adds.

The ultimate goal is to create a “Google-like” search engine that can be used in both a “proactive and reactive” way, Beard says. “On one hand, policy- and decision-makers can look at what others have tried and perhaps even connect with those jurisdictions before embarking on what could be costly changes to the system. On the other, when a patient is harmed, the individual responsible for reviewing that incident can come here first to see how they can improve on previous efforts.”

During the official launch of the site, WHO chair of patient safety Liam Donaldson said the database was the equivalent of an orange wire that’s found disconnected during a preflight inspection of a jumbo jet. The wire is subsequently repaired and the incident is reported to a network of engineers who then check all jets of the same make to ensure the fault is not systemic.

“We’re not there yet with patient safety,” MacLeod says. “But this is much closer to that vision of what the future of incident reporting might look like.”

CPSI also expects to soon debut an online portal for patient safety tools and resources, of which the Global Patient Safety Alerts site will be one.