Report on the participation in the HEPS conference in Strasbourg between 25 and 27 June 2008.

At the conference in Strasbourg representatives of different branches of medicine, psychologists, architects, specialists in information technology attempted to find the best solutions promoting safety of patients undergoing a treatment.

Real patients also had an opportunity to express their opinions at this interdisciplinary conference. Their experiences made the conference participants to reflect on the subject of cooperation between medical staff and patients, the importance of mutual understanding of needs and a necessity to express the objectives clearly by both parties involved in the treatment process.

It was very important for the representatives of the World Patient Safety Alliance to be able to share their opinions, as well as their experiences in getting patients involved in the treatment process. Examples of malpractices, medical errors resulting from a non-use of the procedures, lack of external control of medical equipment involving the so-called human factor were an important element of the meeting.

In fact each session began with discussing stories of patients and a plan to introduce changes to eliminate errors. I was impressed by the story of Christina Perera of Sri Lanka, PFPS leader of Asia, who suffered a lot because of a wrong diagnosis and treatment. However, she still thinks patients’ stories also have and educational aspect to physicians and nurses making them more sensitive to potential tragedies. The thought of Mahatma Gandhi of taking whatever we want to change in our hands kept me haunting long after the session closed.

It was the next time I met Evangelina Vazquez of Mexicio. She came to Strasbourg with her son. When she was telling the story of Uriel, eyes of many participants filled with tears.

It was the first time I had a chance to meet Danish representatives of patients safety movement. Eva Simonsen and Katrine Kirk prepared professional materials for the conference and a film presenting short stories of medical errors in this country.

Apart from the official program of the conference we had a chance to see a film made by an Australian physician, who admitted that he had made an error, however, he managed to correct it when the patient was still lying anaesthetized on the operating table. The physician confused the left cerebral hemisphere with the right hemisphere of the patient undergoing operation. This controversial film divided even us, PFPS leaders, into two groups. I considered the film to be a very good educational material for medical staff, which presented, a bit ironically, how little time medical staff devoted to patients. It showed that medical staff did not talk to patients, treated them instrumentally calling them for example “D3 room patient”, etc., that operations were conducted at random and there were a lot of patient identification mistakes. Some of my colleagues were of the opinion that the film stripped patients of their dignity, that even a small change in a name may have irrevocable effects , e.g. operation on a wrong patient may not be dealt with the way it was presented in the film. I strongly believe that the more films are presented, the more often the subject of malpractices and wrong communication is dealt with in discussions at hospitals, the more often we will think about how to change it.

I presented the story of infected infants in a Lodz hospital, which had been known to PFPS representatives. For six years the case had been pending before court before the mothers of the infants who died in 2002 won it. Since that time all neonatal wards in Poland have been under special control. The mothers have been in e-mail contact and they provide mothers who have any doubts about safe delivery with respective counselling.

Owing to the conference our voice, the voice of patients, could be heard again. Talks behind the scenes made me realize that a lot of physicians, participants of the conference also found the problem important and promised to improve communication at the physician – patient level.

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