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When Healthcare HurtsAn Evidence Based Guide for Best Practices In Global Health Initiatives
By Greg Seager
AuthorHouseCopyright © 2012 Greg Seager
All right reserved.
Chapter OneSelf-Assessment of Short-term Global Health Initiatives
Self-Assessment of Short-term Global Health Initiatives Some may find this chapter challenging, because it is an important starting point: self-assessment. Do we who engage in global health initiatives see ourselves rightly? We must be willing to look honestly at our motives and the quality of services we provide. We are all broken, wounded, and deficient, and we have no hope of helping others until we first realize our own state. The same can be said about the projects and programs we create to serve the poor. Our projects and programs are often broken, and we must see them clearly before we can change them. Before we can create impact and change in others, we must first see clearly the need for change. We have many deficiencies—most of which are knowledge deficiencies, some of which are attitudes and assumptions—that further mar the identity of the poor.
There once was a wise king who cried out, "Search me, O God, and know my heart; try me, and know my anxieties; and see if there is any wicked way in me, and lead me in the way everlasting!" The king understood that there are many things in our thoughts and actions that may appear right but may be wrong. Whether we look outside or inside ourselves, we need to look honestly at our motives. Our motives for engaging in global health initiatives need to be our starting point; this is true for both faith-based and secular programs. The first question on the list of questions posed in the introduction asked whose needs we are trying to serve. This question examines our motives for serving in short-term medical and health projects, and this is an important first step. If our efforts in international health work are really about the recipients of care, not all about us, then we will begin to move patient safety to a place of top priority.
A general medical team was serving a village community in Central America. Maria, a 29-year-old mother of five, arrived at the clinic pharmacy to receive her medication after having her entire family seen by one of the physicians. Maria had three prescriptions for herself, and each child received prescriptions for parasite medications and vitamins. In addition, three of the children were febrile, and two had been diagnosed with otitis media (ear infections) and one with strep pharyngitis (throat infection). Each of them also received prescriptions for antipyretics (Tylenol) and antibiotics. Maria waited patiently with the handful of prescriptions in the pharmacy waiting area. The pharmacy line was long with about 75 people waiting for prescriptions to be filled. There were also people waiting to be seen by the dental, medical, and health education volunteers. Maria finally got to the pharmacy counter, and her prescriptions were filled by a pre-med student under the supervision of a nurse and a paramedic. A paramedic provided instructions for each medication through a translator at the pharmacy counter in front of a crowd of people while Maria was trying to keep her children from getting lost in the crowd. Dosages were explained to Maria, and instructions were written in her own language for the 12-year-old, six-year-old, and six-month-old children. However, Maria could not read. Maria received multiple medications in Ziploc baggies and non-child-resistant containers, and she took them home to her one-room dirt-floor home with no place to store them away from her children. Less than a week after the team left the country, Maria's six-month-old child was brought to the public hospital in that region with acute liver failure and died. Maria had mixed up the dosages of medication and had been overdosing her six-month-old with Tylenol for the entire week.
Patient Safety in Global Health Initiatives
In 2001, the Institute of Medicine published a paper focused on closing the divide between what we know to be good evidence-based healthcare and the healthcare that is actually delivered to patients. This report, entitled "Crossing the quality chasm: A new health system for the 21st century," recommends six strategic aims on which to focus healthcare quality improvement efforts (Institute of Medicine, 2001). They are known as the "aims for improvement," and they are as follows: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. Note that the first and most important of all is patient safety. The Institute of Medicine defines patient safety as "the prevention of harm to patients," and they direct special attention to creating a system of care delivery that "(a) prevents errors; (b) learns from the errors that do occur; and (c) is built on a culture of safety that involves healthcare professionals, organizations, and patients" (Mitchell, 2008). If we take these concepts seriously in our home countries, how important is it that we apply them when we practice as volunteer providers in developing countries?
Global health initiatives have great potential to help and alleviate much suffering, but as Maria's story illustrates, they also have great potential for harm. Both faith-based and humanitarian organizations often enter the realm of healthcare delivery in short-term projects without recognizing the responsibility inherent in healthcare. We often get so caught up in the good we are attempting to do that we lose sight of the potential for harm that is part of any healthcare delivery. We often return home from short-term initiatives reporting the glowing feeling from our time of service. We define the quality of our service by the quality of our experience, the number of patients treated, and the number of prescriptions filled. We rarely consider the potential for harm that comes from such efforts if patient safety is not a top priority.
As healthcare professionals, we agree that there is an ethical and moral responsibility that comes with providing healthcare from which no provider or organization is exempt; this is the responsibility to provide safe care to patients. The World Medical Assembly puts it this way: "Quality assurance should always be a part of healthcare, and physicians in particular, should accept responsibility for being guardians of the quality of medical services" (World Medical Assembly, 1981). The question is, How do we achieve this cross-culturally? Healthcare—wherever it is provided, in North America, in Europe, or in Africa—has the potential to harm the recipients of that care. As healthcare professionals who engage in cross-cultural healthcare activities, we want to accept the responsibility of healthcare delivery to "first do no harm." However, this is not easily achieved even in fully developed countries.
It is estimated that more than 200 Christian healthcare mission teams leave the US alone each month to go somewhere in the developing world (A. Hester, personal communication, September 20, 2011 ; L. Morris, personal communication, September 21, 2011). This does not count strictly humanitarian global health initiatives. In 2010, the two leading suppliers of pharmaceuticals to medical teams, Kingsway Charities and Medical Assistance Programs (MAP) International, sent 3,448 medication shipments, sending a combined total of more than 440 million dollars' worth in pharmaceuticals (Kingsway Charities, 2010; MAP International, 2010). Maria's story demonstrates how the dispensing of hundreds of millions of dollars' worth of medications in developing countries, without significant attention to patient safety, is a recipe for tragedy. The significant volume of such projects combined with the potential for adverse outcomes makes establishing guidelines for patient safety and quality improvement in global health initiatives an operational imperative.
Concerns about short-term global health initiatives and patient safety were first published in the early 1990s in an article entitled "Short-term mission teams enhancing or eroding health" (Montgomery, 1993). In this article, the author concludes that when such projects are assessed from the community-impact perspective, they have little if any positive impact but significant potential for negative consequences. There are a number of documented cases of child deaths relating to short-term global health initiatives. Dupuis (2004) described two children that died in Asia as a result of undergoing cleft surgery in the presence of severe acute malnutrition. One of the primary drivers of quality and patient safety issues in healthcare missions is emphasizing the number of patients seen over the quality of care provided (Garbern, 2010).
In 1999, Operation Smile, a high-profile and well-funded charity focused on cleft surgeries, drew much public scrutiny due to charges of shoddy practices (Abelson & Rosenthol, 1999). Critics charged them with putting the number of surgeries above patient safety for publicity reasons leading to four deaths of children in 1998 and twelve in prior years (Abelson & Rosenthol, 1999). In China, local medical professionals reported that 29% (169) of the children whom Operation Smile operated on had major complications requiring ongoing care and surgical revisions in Chinese hospitals (Abelson & Rosenthol, 1999). These issues were hardly isolated; in Kenya, a child died during surgery as a result of running out of oxygen, and in Vietnam, a child was lost as a result of an asthma attack during surgery, a medical history not uncovered in the pre-op evaluation (Abelson & Rosenthol, 1999). It should be stated that Operation Smile now has an exemplary patient-safety program that is featured on their website as the global standards of care.
What are the chances of someone being harmed by a short-term healthcare project? There is no way to know exactly, partially because little has been done to study community impact. This author has reviewed more than 100 post-outreach surveys assessing the impact on volunteers, but only a few looked at community impact, and none looked deeply at the idea of patient outcomes and safety. Bajkiewicz (2009), in his article "Evaluating short-term missions: How can we improve?" also describes the vast number of survey studies done on short-term volunteers and the incredible paucity of community-impact assessments. The lack of patient outcome monitoring has left us in the dark as to the number of adverse events that actually occur as a result of global health initiatives. Operation Smile's adverse events came to light only after Chinese medical professionals and some of their own volunteers filed a long and detailed complaint to their board of directors. Charity organizations that have experienced bad patient outcomes do not publicize such events, because it is just not good public relations, and funding may be affected. It is reported that Operation Smile lost a ten-million-dollar pending donation that was diverted to another organization over the press received in the late 1990s (Abelson & Rosenthol, 1999). However, short-term programs are not alone in their lack of tracking patient outcomes in developing countries.
There is a paucity of patient-safety research in the developing world that forces us to draw on what has been learned from developed countries. The World Health Organization (WHO) draws most of the evidence base for its patient-safety programs in developing countries from the studies that have been done in developed countries (WHO World Allience for Patient Safety, 2008). The studies that have been done in developed countries on patient safety raise serious concerns about patient safety in global health. They clearly demonstrate that even healthcare provided in developed countries within delivery systems that have the processes and structure necessary to achieve a level of safety can and do fail.
What we do know is that adverse drug reactions are now among the leading causes of death in many countries (World Health Organization, 2005). Adverse drug events alone are estimated to account for 140,000 deaths in the US annually (WHO World Alliance for Patient Safety, 2008), and it is believed that the number of deaths as a direct result of medical errors ranges between 44,000 and 98,000 per year (Institute of Medicine, 2000). One study of ambulatory care in the US showed that 1.4% of hospital admissions were for adverse drug events (Jha, Kuperman, Rittenberg, Teich, & Bates, 2001). Another study showed that 25% of patients who received a prescription from a primary care provider experienced an adverse drug event (Gandhi et al., 2003). Yet another study showed that 5% of elderly patients who were seen in the ambulatory care setting suffered an adverse drug event (Gurwitz et al., 2003). Based on what is known about short-term programs, it is clear there is a much higher risk from healthcare interventions and treatment in such programs. This is especially true when those interventions and treatments occur outside functional healthcare systems. Gorske (2009), in his article "Harm from drugs in short-term missions," outlines 16 common reasons why dispensing drugs in communities as part of short-term projects (as opposed to the hospital or clinic setting) places patients at much greater risk of serious harm (See Table 1).
Table 1. Why patients are at a greater risk of harm from drugs in the short-term mission setting (Gorske, 2009). Used With Author's Permission
* Lack of knowledge of the patient (every patient seen is a new patient)
* Lack of adequate medical record, medication list, allergy record, list of diagnoses, and so on to determine whether a drug may be contraindicated
* Lack of adequate time for obtaining an accurate and complete history
* Lack of adequate time/facilities for obtaining an accurate and complete physical examination
* Lack of availability of reliable laboratory testing
* Lack of adequate provider training and knowledge of World Health Organization international standards and evidence-based practice guidelines for developing countries
* Lack of emergency medical systems and intensive care units for timely and appropriate treatment of adverse effects
* Confusion due to language and cultural differences
* Lack of patient familiarity with a medication's adverse effects
* Lack of adequate time for counseling by a physician, pharmacist, or nurse
* Increased risk of drug interactions and drug overdose
* Disrupted continuity of care for chronic conditions for which the patient is under the care of a local provider
* Increased risk of accidental ingestion related to lack of knowledge of child-safety requirements, safe storage area in home, or child-safe containers
* Increased mortality due to lack of poison control centers, emergency medical systems, and intensive care units for timely and appropriate treatment of accidental ingestions or overdoses
* Lack of availability of follow-up; neither the prescribing provider nor the dispensing pharmacist will be available if there are adverse effects to the treatment
* Local in-country healthcare providers and pharmacy personnel usually have little knowledge of the medications brought by short-term teams and/ or lack the resources to treat drug-related complications
Barriers to Patient Safety in Global Health
In order to improve patient safety in global health initiatives, we must be able to identify barriers that impede patient safety. The greatest barrier to achieving better levels of patient safety in such programs is that they often lack a physical infrastructure through which to provide care. Many short-term programs attempt to provide patient care and dispense medications in churches, schools, or community centers disconnected from any existing health services. Seager, Tazellar, and Seager (2010) describe how this often leads to situations not conducive to safety, citing the following examples: (a) non-medical church volunteers are often used to fill prescriptions, and then instructions are given through translators by a nurse or paramedic; (b) caregivers of children may receive several prescriptions, usually in Ziploc bags, often receiving instructions in front of a crowd of people; (c) those same caregivers then take those baggies of medications home to a one-room dirt-floor house, with no safe place to store them away from children; (d) patients often hold cultural beliefs about the medicines that further cloud their understanding (e.g., big pills are for big people and little pills are for children, red pills are for blood problems and blue are for stomach problems). Dohn and Dohn (2003), in studying the quality of short-term healthcare projects in the Dominican Republic, state that as many as 36% of patients seen by a recent healthcare team had shared the medicines with one or more people, some of whom were children.
Excerpted from When Healthcare Hurts by Greg Seager Copyright © 2012 by Greg Seager. Excerpted by permission of AuthorHouse. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Table of Contents
Chapter 1—Safety First....................1
Chapter 2—Best Practice Guidelines: Where did they come from?....................21
Chapter 3 Patient Safety Culture: What is it and how do we achieve it in global health?....................31
Chapter 4—Training for Transformation: Orienting Global Health Volunteers....................49
Chapter 6—Transformational Partnerships....................101
Chapter 7—Facilitating Transformation....................123
Chapter 8—Medical Records....................159
Chapter 9—Standards for Cross-cultural Healthcare Delivery....................165
Chapter 10— Surgical Global Health Initiatives....................195
Chapter 11—Best Practice Guideline 6 Participatory Design, Monitoring, and Evaluation....................215
Chapter 12—Best Practices Summary....................251