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the anticipated change or finished the investigations things have moved on and the guidance or recommendations are out of date.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.