Rethinking Patient Safety Chapter 1

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.