What is the ‘do no harm’ principle in medicine?

To ‘do no harm’ is the ethical foundation of professionalism in medicine. Consequently, it is ingrained in physicians to be concerned about making errors and being blamed for errors. But what does it actually mean? Here, we’ll explore its facets and look a little closer at what is meant by patient safety.

First, do no harm

Non-maleficence is the way ‘do no harm’ is expressed in the context of bioethics – adverse events in medicine rarely arise out of maleficence or ill intent from a physician.

A second ethical precept is beneficence – that what we do provides benefit to the patient.

In addiction medicine, a simple example might be providing counselling for someone with alcohol use disorder. It is non-maleficence, but is it beneficent? What about offering medication for alcohol use disorder without counseling. Is that non-maleficent and beneficent?

In cases such as these, we rely on the available evidence, clinical consensus, and shared-decision making with the patient – a process that recognises and dignifies their autonomy.

What is meant by patient safety in medicine?

The simplest definition of patient safety is the “freedom from accidental or preventable injuries produced by medical care,” according to The Agency for Healthcare Research and Quality (AHRQ).

The American Board of Medical Specialties (ABMS) further elaborates: “the prevention of harm to patients” emphasises a system of care delivery that

• prevents errors.
• learns from errors that do occur.
• is built on a culture of safety that involves healthcare professionals, organizations, and patients.

Errors result from both acts of omission and acts of commission.

“To err is human, but errors can be prevented.”

In addition to being concerned about making errors, physicians are concerned about being blamed for errors. To err may be human, but our system or culture is not always forgiving of errors.

At the same time, our system and culture do not always find ways to prevent errors from occurring or learn from them when they do happen. This is often followed by blame, or at best a narrow focus on how and when the error occurred. The way we tend to apportion blame can serve to perpetuate a cycle of patient harm or near harm.

To make patients safer, we need to create a culture of safety inside health care organisations and teams that allows us to anticipate and prevent or reduce errors.

A culture of safety requires:

• Safety practices in which we identify and learn from errors when they occur. This includes changing practices to prevent the same error from happening repeatedly.
• Safe systems which begin with understanding how systems and processes at the organisational level can contribute to errors. Systems thinking is used to anticipate situations in which errors become more likely, modifying processes within the health care organisation and standardising the implementation of safer practices to reduce the risk and, ultimately, the rate of errors.

Patient safety is a public health concern

In the same way that opioid use disorder is now thought of as a public health concern, so too should issues of patient safety.

Patient safety encompasses not only morbidity and mortality, but harms such as loss of dignity and respect. This is a particularly significant concern for providers like us specialising in addiction, as so many of our patients have experienced a great deal of harm due to loss of dignity and respect.

Patient safety applies to every care setting

While we generally consider harm to patients as occurring in clinical settings, it is important to consider the harms that patients can experience outside clinical settings.

These locations can include not only hospitals, but also ambulatory care clinics, freestanding surgical and diagnostic centers, long-term care facilities, and even patients’ homes.

Providers need to keep in mind not only what’s needed for the safety of people with substance use disorders while in the inpatient setting, but also the person’s safety needs in every care setting. It is easy to forget that if a patient is taking medication at home, their home becomes a care setting. For this reason, the home, as well as the other locations mentioned, are within the scope of patient safety concerns.

What does patient safety mean in a non-clinical setting?

Here is an example of how patient safety can be promoted in non-clinical settings: Providing naloxone to people who use drugs after a non-fatal overdose before they leave the emergency department, or, leaving behind naloxone when an overdose has been reversed by paramedics at home, which can reduce risk of fatal overdose in the future for the individual. This qualifies as a safe practice improvement to patient safety.