Patient Safety Initiatives in the Indian Subcontinent

India, which is the second most populated country in the globe, has been facing dual burden of communicable and non-communicable diseases in the last three decades.¹ To manage this enormous case load, India is enrolling more than 80,000 MBBS (medical) students each year in its 541 medical colleges to achieve the goal of one doctor (MBBS) for every 1000 population {World Health Organization (WHO)} in India by the year 2024.² We have been training more than 75,000 specialists annually to meet the huge demand of overburdened healthcare. It is estimated that a minimum 20-person specialist workforce of surgical, anaesthesia and obstetric professionals (SAO) will be required per 100,000 population by 2030, to effectively reduce maternal mortality.³ In addition, a minimum of four anaesthesia providers are recommended for every 100,000 population.⁴

India has approximately 45,000 qualified anaesthesiologists {diploma (DA), postgraduate degrees (MD) and Diplomat of National Board (DNB) credentialed} of which around 36,000 are members of the Indian Society of Anaesthesiologists (ISA). Data from the ISA reveals a substantial shortage in the anaesthesia work force (only 1.27 anesthesiologists for every 100,000 people) in India, while the United States has 30 anesthesiologists per 100,000 population.⁵ Unfortunately, a majority of the trained anesthesiologists in India prefer to work in urban areas, leaving the rural locations deprived of their services. Besides a shortage of trained anesthesia personnel, there is also dearth of drugs, equipment, and monitoring devices in rural areas.⁶ To evaluate the availability of essential monitoring and emergency medical equipment, an online survey was conducted in a broad cross section of Indian hospitals (teaching, non-teaching hospitals, government, and private medical colleges). After analysing 600 responses, the survey findings suggested that while teaching hospitals were better equipped than other hospital types in terms of monitoring and equipment, the availability of advanced monitoring and emergency management equipment (e.g. ultrasound machines, defibrillators, cricothyrotomy kits, etc.) was low in all sectors and required immediate action.⁷

To overcome important safety-related concerns within Indian hospitals, a number of patient safety initiatives have been suggested. While some of these initiatives are already in place nationally (Table 1) others are in the pipeline under the purview of the ISA, the World Federation of Societies of Anesthesiologists (WFSA), and the WHO. One of these suggested safety measures widely used in India is the 19-point Surgical Safety Checklist (Table 2) recommended by WHO.⁸ In addition to the surgical safety checklist, the ISA reached a key safety milestone in 2021 with the introduction of a national registry of all anesthesiologists in the country. The ISA has also prioritized three important safety initiatives i) development of a culture of safety with collective teamwork ii) early identification of deterioration and preventive measures and iii) concerns during anaesthesia at remote locations. In addition, the ISA is encouraging healthcare professionals to use digital technology for record keeping and data analysis.⁹

Table 1. Patient Safety initiatives in India

Ayushman Bharat Yojana (A national scheme to provide healthcare support)

Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) (National insurance scheme )

LaQshya’ programme (Labour Room Quality Improvement Initiative)

National Health Mission.

Ayushman Bharat Digital Mission (ADHM) (National data in electronic format)

PM Ayushman Bharat (National Healthcare Infrastructure Mission)

Table 2. World Health Organization (WHO) Surgical Safety Checklist

Time point
1. Time in	Prior to induction (7 points)
2. Time out	Just before giving incision (7 points)
3. Sign out	Prior to shifting patient out of operating room (5 points)

Since the mid-1990s, perioperative safety efforts in India have focused on the importance of early identification and prevention of critical incidents =. In line with this focus the ISA has increased patient safety efforts by the formulation of a variety preoperative anaesthesia guidelines (e.g. fasting guidelines, essential preoperative evaluations and guidelines for COVID-19 patients posted for emergency surgery). In addition the ISA sponsors regular academic activities with a patient safety emphasis.^10,11

Monitoring: Lack of monitoring is a major concern in developing countries including India. The WFSA has been instrumental in addressing this patient safety issue through its launching of the Life Box Foundation and Global Oximetry Project. The ‘safe anesthesia, safe country’ initiative of the WFSA in collaboration with the ISA has provided low-cost pulse oximeters to those centres devoid of them. The health care personnel trained under the programme of ‘Safer Anaesthesia From Education’ (SAFE), have received education about monitoring, detecting, and management of perioperative hypoxemia.¹² Many developing countries such as India do not regularly collect data on perioperative safety issues, and therefore epidemiologic analyses of the types and frequencies of patient safety events which occur nationally are currently unknown.

Infection Control: An intriguing prospective study which analyzed infection control measures (floor cleaning, surgical gloves, and skin preparation) at twenty hospitals in the Indian state of Gujarat, reported insufficient preventive infection measures. Improvements in hygiene may drastically lower the infection rate, which can be accomplished by implementing standardized best evidence-based practices.¹³ A unique 9-month observational study in an Indian multispecialty hospital also identified a deficiencies in adherence to infection control guidelines as well poor surgical safety precautions. The study advocated an immediate overhaul of policies to educate and implement patient safety measures by all staff.¹⁴

Quality Care: The Quality Council of India was formed by the Government of India, to improve the quality of a variety of dimensions of work. Furthermore, to ensure the safety of both (patients and health care provider), the National Accreditation Board for Hospitals and Health Care Providers (NABH) was established. NABH has improved the standardization of care, across the country, providing accreditation to healthcare facilities and currently possesses a robust system for regular assessment of hospitals to maintain quality.¹⁵

Patient safety monitoring : The safety of patients is a goal for all healthcare organizations, eliminating errors can significantly reduce the morbitity and mortality.. Numerous aims and objectives have been incorporated into India’s National Patient Safety Implementation and Framework (NPSIF 2018-2025) consisting of 6 main objectives (Table 3). These objectives have been developed to enhance and strengthen the patient safety practice. NPSIF’s priorities (Table 4) are made to implement standard operating procedures, surgical safety checklist and to enhance the patient safety research in India.¹⁷ Special emphasis has also been given to expedite education of healthcare providers by conducting seminars, workshops, and conferences.¹⁸ In addition, regular audits of patient safety practices are becoming a part of hospital policy, which will make the protocols more robust and safe.

Table 3. Objectives of India’s National Patient Safety Implementation and Framework (NPSIF)

To improve the structural system, to support quality, safety and efficiency To assess the nature and scale of an adverse event Ensure a competent and capable workforce Prevention of infection Implementation of global patient safety programme To strengthen the capacity of patient safety research

Table 4. India’s National Patient Safety Implementation and Framework (NPSIF) Key Objectives

1. To improve the structural system, to support quality, safety and efficiency	Institutionalize patient safety and strengthen legislative and regulatory framework Strengthen quality assurance mechanisms, including accreditation system Establishing a culture of safety and improving communication Identification, handing over transfer protocols in healthcare facilities Establishing patient-centered care and involving patients as partners in their own care
2. To assess the nature and scale of adverse events in health care and establish a system of reporting and learning	Generating evidence Establishing robust surveillance system Ensuring supportive legislative mechanisms for effective functioning of patient Safety surveillance systems
3. To ensure a competent and capable workforce that is aware and sensitive to patient safety	Strengthening education, training and professional performance Improving the understanding and application of patient safety and risk management in health care
4. To prevent and control health-care associated infections	Strengthening infection prevention and control across all healthcare services and all levels of care Providing appropriately cleaned, disinfected or sterilized equipment Providing a safe and clean environment by improving the general hygiene, sanitation, and management of healthcare waste
5. To implement global patient safety campaigns and strengthening patient safety across all programs	Safe surgical care Safe childbirth Safe injections Medication Safety Blood Safety Medical device safety Safe organ, tissue and cell transplantation and donation
6. To strengthen capacity for and improve patient safety research	Consolidation of patient safety research and Reinforcing research for patient safety

Conclusion

Patient safety initiatives have been playing an important role to reduce morbidity and mortality in India. These efforts are an ongoing process and regular modifications and upgradations are being done to ensure appropriate delivery of health care and safety. India is rapidly upgrading healthcare facilities and improving the infrastructure to address the need of our huge population. India is steadily achieving the mammoth goal to deliver safe anaesthesia and surgical services to all.

 

Jayashree Sood, MD, FFARCS, PGDHHM, FICA
Senior Consultant & Chairperson, Institute of Anaesthesiology, Pain and Perioperative Medicine,
Sir Ganga Ram hospital, New Delhi-110060, India.

Bhuwan Chand Panday, MD
Senior Consultant, Institute of Anaesthesiology, Pain and Perioperative Medicine,
Sir Ganga Ram hospital, New Delhi-110060, India.

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The authors have no conflicts of interest.

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