Nepal has made significant progress in health care since the reinstatement of democracy in 1990. The number of medical graduates and private hospitals has increased sharply, which has made health care more accessible. At the same time, public expectations from health care givers have increased, and demands for more efficient health care management have grown. Lately, reports of an increase in medical incidents have become more frequent. Although complications can happen during the care delivery process, there doesn’t seem to be a robust mechanism to report, investigate and manage the incidents within health care organisations. 

Maintaining trust

A clinical incident is any unwanted and unplanned event which causes, or has the potential to cause, harm to a patient. There has to be a mechanism in all health institutions to report all incidents which may occur during a patient’s journey in each episode of care. 

One of the consequences of an increase in the number of incidents in health care is loss of trust of patients, consumers and the community. The uncertainty that is integral to health care provision, the consequences of failing to manage this uncertainty, and the intimate nature of the services provided mean that trust must underlie the relationship between patients, providers and the health institution. This is especially important in Nepal due to the absence of health information and also unequal power relationships. 

Historically, the doctor-patient trust was supposed to be an automatic occurrence. But in the modern era of open communication and access to information, patients’ trust of clinicians is increasingly likely to be conditional or ‘earned’ based on their experience of care. This requires a change in the focus of the training provided to the new generation of medical graduates in the developing world, where communication skills and medical ethics become part of medical competencies. But in Nepal, the focus has been diverted from improving the culture of health care delivery with an over emphasis on rationality, accountability and regulation. 

It is hard to define the quality of health care as it depends on a range of different factors. However, there is an internationally accepted framework to outline the quality of health care under the domains of safety, quality, effectiveness, appropriateness, patient centrism and equity. In the current context of Nepal, the safety and quality of health care are major concerns. Incident management and learning from them are major components of promoting safety. Health care delivery is a complex process, and it involves a chain of factors. The focus in Nepal is less on the individual who makes the error and more on the care delivery process and pre-existing organisational factors. 

Protocols and policies are designed as barriers to protect against hazards and to mitigate the consequences of human failure. In the analysis of an incident, each of these elements is considered, starting with the unsafe act and failed defences and working back to the organisational processes. The first step in any analysis is to identify active failures—unsafe acts or omissions committed by health care professionals. Then the investigation considers the wider organisational issues to identify the contributory factors. It is important to remember that the person who provides care to the patient at the sharp end may have only a little or no role in a particular incident. 

Steps to take

Timely and effective incident management is key to gaining public confidence. The first step in incident management is identification of the incident. Once identified, the incident has to be reported through the proper channel. There has to be a clear communication to the patient and the family through the process of open disclosure. It may also be necessary to take immediate action to mitigate the harmful consequences of the incident while the investigation continues. In the next step, the incident has to be graded according to its severity. 

Likewise, incidents and complications in health care delivery are not rare occurrences, and there is a chain of hidden events behind their occurrance. Human error at the sharp end is easy to identify, but blaming one individual won’t solve the problem. Each incident must be investigated thoroughly, and the care delivery process has to be closely scrutinised. There is also a need for robust clinical governance to restore public trust. There has to be a framework through which health care organisations and individual clinicians are made accountable for continuously improving the quality of their services and safeguarding high standards of clinical care.

In many countries, medical indemnity is mandatory to work as a health professional. Health workers in private practice must have their own indemnity insurance. This covers the health professional for both legal costs and the cost of compensation if the health professional is found to have caused harm by committing an error, omission or negligent act. 

There has to be a commitment by the health service and local government agencies to ensure a safe and secure environment for health professionals. Violence and aggression shouldn’t have any place in hospitals and clinics. A therapeutic relationship between the patient and health care providers can’t be established when there is an environment of mistrust. People who get involved in violent acts must be punished according to the existing laws or new laws have to be passed if the existing ones are not strict enough. The Nepal Medical Association has demanded jail without bail which might be an option until the legislative framework gets established. 

Dr Chapagain is the clinical director at Tablelands Mental Health Services,  New South Wales, Australia