Patient safety and iatrogenesis

Andreu Segura

Among the most important public health problems today, the harmful effects associated with clinical and health care practice stand out, the relevance of which is unquestionable given their impact and, above all, their aetiology. Hence the development of the so-called patient safety strategy, the purpose of which is to limit as much as possible the damage that medical and health care interventions can cause provided that such damage can be avoided.

Panagioti et al. published a systematic review and a meta-analysis of the studies registered in Medline, PubMed, PsycINFO, Cinahly Embase, WHOLIS, Google Scholar and SIGLE from January 2000 to January 2019 intending to quantify systematically the prevalence, severity, and nature of avoidable harm to patients cared for in services that provide medical care around the world.

Precisely one of the most original characteristics of the study is the choice of avoidable damage as a dependent variable, an approach that meant restricting the sample to almost 1% since the classification of damage as avoidable did not correspond to the same criteria according to each investigation. In any case, of the more than 7,000 papers initially reviewed, 70 could finally be included with a total of 337,025 patients. Among them, the global prevalence of avoidable damage was 6% of the patients, that is, one affected out of every 17 treated, two of whom had suffered serious damage. 25% of the preventable damages were associated with medication and 24% with other treatments, which are among those most frequently provided in the specialities of surgery and intensive care. (1)

The authors are aware that the international patient safety policy promotes placing avoidable damage as the main objective of safety actions. They are also well aware of the very few quality improvement initiatives specifically targeting incidents of preventable harm rather than harm in general (avoidable or not), as suggested by so many studies of the first selection have been ruled out. Therefore, they focus on stimulating the growth of strategies with an empirical base specifically contrasted and aimed at preventable harm to the patient, since they would logically lead to improvements in the quality of care that could also be more efficient. 

Geoffrey Rose (1926-1993)

and Roses’s strategy of preventive medicine (1992)

Limiting actions to those that are supposedly most effective recalls in a certain way the dilemma raised by Geoffrey Rose in his preventive medicine strategy (2) when he compared the advantages and disadvantages of global prevention aimed at the whole population with that of prevention limited to high-risk groups. 

Acting against all causes of all possible harm isn’t comparable to the population strategy for the prevention of many chronic diseases, since we know that some harmful effects of medical and health interventions are inseparable from the benefit they seek. The only way to avoid all the damage attributable to clinical and health interventions would be not to carry them out, following the famous aphorism advocated by Chomel and attributed to Hippocrates or Galen: Primum non-nocere. If the aim is to not harm, it’s better to do nothing, because it’s not possible to guarantee the safety of any of the large number of prophylactic, diagnostic, therapeutic or rehabilitative measures that exist 100% of the time. The current advocates of medical nihilism (3), whose historical antecedents go back to Skoda and the Vienna school (4), insist on this fantasy of total harmlessness. A drastic approach that, of course, would mean giving up the benefits that are really due to the interventions undertaken.

Therefore, it’s essential to recognize the avoidable harmful effects. According to Nabhan, avoidable harmful effects are "those that result from an identifiable and modifiable cause, whose future recurrence can be avoided through a reasonable adaptation of the process or adherence to the appropriate guidelines" (5). But this definition doesn’t enjoy universal consensus, mainly because the notion of an avoidable harmful effect is circumstantial since what was not avoidable yesterday may be so today.

This limitation doesn’t have to amend the strategic proposal, since it’s about reducing the damage as much as possible without giving up the desired benefits. However, too often, the benefit sought isn’t sufficient to expose the patient or the public to the risk of potential harm that –more often than it seems– is the consequence of overdiagnosis. We should remember here that even when making mistakes is human, it’s also human to be ashamed of it and even to deny yourself. For this reason, it may also be appropriate in this case to follow Rose's global approach, remembering that the excessive population decline in risk factors can also be detrimental.

The term "patient safety" to refer to the prevention of the potentially harmful effects of clinical and health care practice may therefore not be the most appropriate. Not only because of the difficulty of distinguishing avoidable harmful effects from those that are not, even if they may be in the future, but also because it focuses, even by evocation, on errors and bad practice - even if it’s systemic - as the main aetiology, when perhaps the medical and health care interventionism that encourages indiscriminate consumerism is more decisive. 

Hence the recourse to the slightly older, but not obsolete, concept of iatrogenesis (6) which, according to the dictionary, is what doctors do, particularly if it’s harmful. Although the harm associated with clinical and health care practice isn’t limited to medicine, its central role in health care can be used as a symbol of the whole and, perhaps more importantly, its meaning isn’t reduced to errors and bad practices that, although to err is human, they don’t invite us to recognize them.

Bibliography

(1) Panagioti M, Khan K, Keers RN, Abuzour A, Phipps D, Kontopantelis E, Bower P, Campbell S, Haneef R, Avery AJ, Ashcroft DM. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ 2019; 366: l4185.  

(2) Rose G. The strategy of Preventive Medicine. Oxford University Press, 1993, 160 p.

(3) Stenga J. Medical Nihilism. Oxford University Press, 2018, 227 p. 

(4) Sakula A. Joseph Skoda 1805-81: a centenary tribute to a pioneer of thoracic medicine. Thorax 1981; 36: 404–11.

(5) Nabhan M, Elraiyah T, Brown DR et al. What is preventable harm in the health care? A systematic review of definitions. BMC Health Serv Res 2012; 12: 128.

(6) Segura A. La iatrogenia en atención primaria. FMC. 2019;26(10):529-31.