Rethinking Patient Safety Chapter 2

Suzette Woodward

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.