Socrates said that a life un-examined is not worth living. In our re(think) patient safety work which includes ‘getting beneath the surface’ we want to examine patient safety and truly understand how systematic certain mistakes are, how we repeat them again and again and how we could avoid some of them. And. We really want to understand why certain things are not implemented and others are.
We need to consider our past actions, things that were considered completely reasonable at the time and ask if they are still reasonable. Once we re(think) these old choices we can open ourselves to new choices, new opportunities. We may even stop ourselves in our tracks and take a different path.
For example over the last fifteen years I have witnessed numerous presentations on hand hygiene. Evidence which clearly shows that low hand washing compliance has a strong causal link with transmission of infection. Evidence is some change but I have never seen one that says we have cracked it; say 100% compliance which had been sustained for over 5 years. Imagine that. If you have seen this, then please point them in my direction. Sadly time and time again I witness the eager trying to tackle this problem with similar successful or not quite successful compliance rates.
Lewis Carroll’s ‘Alice’s Adventures ..’ and ‘Through the looking glass’ have some wonderful quotes that could easily apply to our patient safety challenges.
‘She generally gave herself very good advice (though she very seldom followed it)’
‘She who saves a single soul saves the universe’
‘When she thought it over afterwards it occurred to her that she ought to have wondered at this but it all seemed quite natural at the time’
‘It’s a poor sort of memory that only works backwards’
‘Finding meaning, like losing meaning, involves pleasure as well as pain’
Like Alice we need to get curious- we need to seek to understand more about why things have not worked as well as we had hoped. We may even start to look though a different lens. That of when things go well rather than when they go wrong. If we know what it looks like when patient safety thrives then we could see if can replicate that.
As Maya Angelou says ‘I think a hero is any person really intent on making this a better place for all people’.
Patient Safety Now 