Patient Safety is hard

Its time we stopped beating ourselves up.  Patient Safety or improving the safety of patient care is hard. In today’s world we have spell checkers and prompts to help us with difficult problems.  We have search engines which help us find the most obscure and wonderful facts and figures.  There are even designs that help us get things right; large handles to pull a door (rather than flat plates to push), cordless kettles, brakes and accelerator pedals in the same place on every car.  But for many problems in life and in particular in areas like patient safety there is no easy solution.  So what are some of the things to consider?

expertise – we really should be respecting patient safety as a science that needs scientists – a person who is studying or has expert knowledge of one or more fields.  But with very little on offer to help people develop this expertise (and I dont mean the odd day at a conference) – people struggle on their own to figure out this hugely complex subject.  This also means not diluting its importance by focusing on quality instead (even though we know that quality is supposed to combine safety, patient experience and effectivness – in reality the nuances, the niche or unique aspects of safety are lost)

  • Imagine conducting a full root cause analysis of an incident which had directly led to one or more deaths with no training or experience;
  • Imagine talking to a parent about the serious life threatening error that their child has been affected by with no training or experience;
  • Imagine trying to get a whole organisation to change a particular procedure or piece of equipment they all are wedded to doing or using with no training or experience.

clarity about what works – it is particularly hard to make good decisions when there are competing choices or priorities and it is not clear which interventions work better than others – for example there is a lot of confusing research and data in patient safety; for every researcher that suggests a particular intervention reduces harm you will find another researcher who says it makes no difference – we need to find a way which helps us know which ones to bother with and which ones to park and which ones to stop and ignore altogether.

design– unlike the examples above, we dont seem to use the same principles to design healthcare equipment or packages.  Too many machines have buttons in the wrong place that if pressed accidentally could cause the machine to be turned off rather than a different expected function.  We have to incorporate human factors into design; Don Norman’s wonderful book The Design of Everyday Things written in 1990 is a must read for those working in patient safety.

understand the context – healthcare practitioners will want you to understand how and where they work rather than assume you know. That means getting out there, experiencing what they do; stepping in their shoes as much as you can – not just ethnography, actually experiencing it; this goes for the patients experience too.  Sitting in a wheelchair for the day, getting from theatres to the ward quickly when the crash bleep goes off, trying to wash your hands between each patient contact and so on.

My list of four items above just touch the surface of the patient safety field.  So stop beating yourself up.  Patient safety is hard.  But take heart that you are not alone.  One thing the patient safety field is not short of is a mass of individuals who are committed to figuring it out and reducing the difficulty so that we can truly make that difference we are all aiming for.

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