In this chapter I describe the research and current data collections in relation to the scale of the problem.  Case note reviews are the main way in which the estimations have been made so far.  They have had their fair share of critics.  For example, I share the arguments set out by Helen Hogan and her colleagues about the limitations of even the most carefully structured case review …

• They only provide a snapshot of a particular episode of care, and a particular time and place
• The opinions of reviewers have been found to be subjective and varied.  The judgement of those reviewers is described as the ‘Achilles’ heel’ of record review studies
• The variation includes; the estimates of life expectancy, the subjective element in judgments of avoidability and the quality of care.  For example; preventability is usually measured on a 1 to 6 Likert scale with preventable deaths defined as those scoring 4 and above.  Reviewers find it difficult to agree on these measures
• There are particular issues relating to deaths associated with unsafe care. Often, these are the deaths of patients who were very ill with an already poor prognosis regarding their original illness or condition.  Reviewers find it difficult to agree on whether the death was as a result of the unsafe care or their illness
• The quality of the case notes themselves is an issue, in that they are often incomplete
• Hindsight and outcome bias influences the judgment of causation and preventability

So even though there has been study after study across the world about how much ‘harm’ there is in healthcare, I would argue not only do we still not know the actual amount we are also too fixated on trying to either find out or describe it.

It is a distraction to continually argue about the numbers of patients affected or whether something is either an avoidable harm or unavoidable harm.  While we know that systems such as healthcare can never be completely safe, it does not mean that we cant have the view that one harm is too much.  Therefore, effort should be more targeted on learning about what happens across the system, all of the time (not just when something has gone wrong) in order to learn about how that system / workplace maintains its safety to its best ability and then continuously use that learning to improve.

Chapter one provides a brief history of patient safety over the last two centuries – clearly it only skims the surface but demonstrates how little by little what was considered acceptable (risk and harm) over time because unacceptable.  There is also the illusion or delusion that we will ‘get to a point where everyone is safe’ – our work will never be done and so instead of seeing the work as getting to an end point, we need to change the mind-set.  Patient safety requires constant attention forever.  As Professor James Reason says in the foreword to Close Calls by Carl Macrae (2014), there are not enough trees in the rainforest to write a set of procedures that will guarantee freedom from harm.

I explore ‘what exactly do we all mean by patient safety’.  Ask a group of people and there will be a huge variation in what they think it is.  A patient will often talk about wanting to feel safe, that they want to feel that the people who are providing their care know what they are doing and are competent and it is assumed that they (the practitioners) wont do anything wrong.  Those that work in healthcare will provide a variety of responses when asked what they think patient safety is…

• It is about keeping people physically safe (no falls, no hitting their had on a shelf, no getting lost or preventing infections)
• It is about risk management, governance and reporting incidents
• It is about reducing medical error or mistakes

Everyone says things like ‘we must take patient safety seriously’, ‘it is our number one priority’.  But there is also a confusion between definitions of effectiveness, quality, competence, and safety.  There are those that think they should be combined and those that think they should be separate.  I argue that there are unique aspects of patient safety that require a unique focus.

The focus seems to have shifted away from understanding human error and risk, two vital components of patient safety, to a focus on quality and quality improvement. This is diverting attention from the unique and specific aspects of patient safety that require addressing; it is also diverting research and resources away from safety and safety improvement.  Safety is an essential building block for achieving high performance in all other areas. The quest for safety is not opposed to pursuing other aspects of quality, but there is a need for a distinct and separate focus on safety rather than it being simply a component of quality.

In this chapter I share the stories of early pioneers of patient safety; Florence Nightingale, Ignaz Semmelweis, Ernst Codman and Herbert William Heinrich and the more recent opinion leaders; Jens Rasmussen, James Reason, Lucian Leape, Charles Vincent, Sir Liam Donaldson and Don Berwick.

 

Like all introductions I wanted to set the scene.

Over the last two decades in particular there has been a concerted effort to understand ‘safety’ and to figure out the scale and nature of the problem as well as the potential solution’s that could be used to improve the safety of healthcare.

We know that in all high risk industries – things will always go wrong.  This is the very nature of our world.  There are those that seek ‘zero harm’ but as hard as it is to hear and to experience, this can never be the case.  All we can promise to do for patients, their families and the staff that care for them is to carry out our work, the tasks, the procedures and treatments we provide in the safest way we possibly can.

The way we have gone about patient safety to date is to try to fix each problem as they arise; one harm at a time.  Whether this be though looking at one incident at a time, one case, one complaint, or one litigation claim at a time or by focusing on one topic at a time; one pressure ulcer, one fall or one infection and so on.  Safety has become a set of ‘projects’ and not a way of life.  But saying it needs to be embedded into our everyday thinking and actions is easy to say and extremely hard to do so we fall back on the easier approach – find out where we are going wrong and try to fix it.

In the meantime the world has changed – while the work of patient safety has stayed the same.

We live in a digital age of social media and instant communication and information, a questioning world, one where there are expectations that we can react fast, make changes quickly and above all be completely open and transparent.

Yet we spend months and sometimes years to write a new procedure or introduce a new way of working or investigate when things go wrong.  When we have finally finished the procedural guidelines or  disseminated the anticipated change or finished the investigations things have moved on and the guidance or recommendations are out of date.  I would argue that we need to take a hard look at what we have learnt, what has worked and what hasn’t and think about taking a different approach.

The rest of the book builds this case.

 

A quick introduction to the Rethinking Patient Safety Blog Series.

In 2016 I took 6 months to write a book .. well actually I took 20 years in a way, because the book was based on my thoughts, feelings and reflections of  the world of patient safety for the last two decades.

Over the next set of blogs I will share snippets from each chapter and also add further reflections on each chapter, as in all things in life, learning never stands still.

At the end of the blog series I will also let you know my thoughts and ideas for the next book.  Yes – exciting for me, there is going to be a second book which will build on rethinking patient safety and am currently writing the outline for the publishers.

I hope that you will find this series helpful – for those that have not bought the book it will provide you with insights and hopefully will stimulate your thinking.  For those of you who have bought the book I hope you will enjoy the additional reflections that enhance your reading further.

Suzette