[Re: https://www.hifa.org/dgroups-rss/spotlight-patient-safety-and-ncds-10-q2... ]
Dear Neil and colleagues,
Thank you for convening this Spotlight. I write from Somos Amigos Medical Missions, which has run a free primary medical and dental clinic in El Naranjito, high in the mountains above San José de las Matas, Dominican Republic, since 1997. We serve 32 rural communities, and hypertension and diabetes are among the conditions we see most often. On Question 2 — the causes of unsafe NCD care and the place of reliable information within it — I would like to offer the view from one small clinic rather than add to the excellent general points already made.
In our setting, the most common form of unsafe NCD care is not a dramatic clinical error. It is a quiet failure of continuity. An elderly woman's dangerously high blood pressure is revealed on a routine visit to our clinic. She is prescribed appropriate medications and advised to return in ninety days. But the clinic is a long, costly journey on the mountain's rough roads; she is the caretaker of her young grandchildren and she also looks after an incapacitated neighbor who depends on her for his meals. The follow-up visit does not happen. Her 90-day supply of anti-hypertensives has run out, and while she would only reluctantly admit it, she has shared some with her neighbor. No one knows any of this until she returns months later, having obviously suffered a stroke, or she does not return at all. Nothing in that sequence would appear in any incident report, yet each gap is a safety event in the life of someone living with a lifelong condition. "No news" is too easily mistaken for good news.
Reliable information sits at the center of this, and it fails in two directions. The patient needs to understand — in plain Spanish, and often without relying on the written word — what her diagnosis means and why a medicine still matters on the days she feels perfectly well. And we, as a small and mostly volunteer-supported clinic, need her information to travel with her care: a record the next clinician can pick up, a medication list the pharmacy and the prescriber both work from, a way to know whether a referral down the mountain was ever completed. When that information is fragmented, safe management of a chronic disease becomes almost impossible, however skilled the individual clinician.
Turning to Question 4 — what has helped us is to treat these gaps as the safety problem, and to design against them with the modest means we have. We try to make the screening-to-follow-up step a deliberate hand-off rather than an outcome left to chance; to keep a simple register of our highest-risk patients so they are actively recalled rather than passively awaited; and to invest in clear, reusable patient-education materials, so that whether a patient understands her own condition does not depend on how much time a particular clinician happened to have that day. None of this requires sophisticated technology. It requires deciding that continuity is itself a safety practice, and organizing and staffing around that belief.
I would gladly share more with anyone working in similar settings, and I am learning a great deal from this discussion.
With best wishes,
Frank Brightwell
Founder and Executive Director
Somos Amigos Medical Missions
Dominican Republic
HIFA profile: Frank Brightwell is Executive Director at Somos Amigos Medical Missions, in the United States. Email: frank AT somosamigos.org