Two things triggered the book.
First, was the nagging feeling that we should be rethinking our approach to patient safety and second, was something I heard in a webinar I was listening to on May 27, 2015. Kaveh Shojania said that incident reporting ‘is the single biggest waste of time in the last fifteen years’ and ‘the most mistranslated intervention from aviation’ (Shojania 2015). This started my thinking on whether not only was this statement correct but also whether there were any other aspects of patient safety that this line could be attributed to.
What else had been a waste of time over the last fifteen years?
When I was listening to the webinar with Kaveh Shojania (2015) he also mentioned that he was co-chairing, with Don Berwick, a review on behalf of the National Patient Safety Foundation (NPSF) (2015) in the US. I looked this up. This review group wanted to galvanise the field to move forward over the next fifteen years with a unified view of the future of patient safety to create a world where patients and those who care for them are free from avoidable harm.
So what have we learnt from the last fifteen years?
In March 2000, the British Medical Journal produced a whole issue devoted to Reducing Error Improving Safety. I still have my much thumbed through copy today. This was the moment that I genuinely thought we would truly transform the safety of patient care. A journal devoted to patient safety was extremely rare at the time.
The editor Richard Smith stated in his editorial that it is essential that doctors, patients and politicians worldwide grasp the scale of the problem and in their article, ‘Safe healthcare: are we up to it?’, Lucian Leape and Don Berwick (2000) wrote about the ‘error prevention movement’. In a prophetic statement, they said,
‘making more fundamental and lasting changes that will have a major impact on patient safety is much more difficult that simply installing new technologies’
They told us that there are no ‘quick fixes’ and that it was important to redesign our many and complex systems to make them less vulnerable to human error.
Significantly Leape and Berwick (2000) talked about how it was important to focus on culture as much as technical aspects of safety and to focus on the working conditions of staff and on how humans interact with one another. Leape and Berwick wrote this as a powerful ‘call to action’ to mobilise people to make safety a priority.
This call to action asked us to promise patients and the public that they will not be harmed by the care that is supposed to help them; ‘we own them nothing less and that debt is now due’ (Leape and Berwick 2000).
For the following sixteen years these two leaders have repeated this mantra; they have said it in multiple different ways but at the heart of all their work is the desire to stop patients from being unnecessarily harmed. If you read the call to action by Leape and Berwick back in 2000, you can feel the urgency in their words, you can feel the frustration but you can also feel the hope.
What did we do with that hope?
Since that year, terms like patient safety, root cause analysis, systems approach to safety, safety culture and just culture have become commonplace. Across the globe people have designed, developed and disseminated all sorts of interventions, initiatives and guidance. The language of patient safety has become embedded in that of policymakers, academics, healthcare workers and the media. Individual countries have set up national bodies, national databases to collect incidents, and there has been international guidance such as the WHO surgical checklist referred to earlier and other global campaigns such as improving hand hygiene and cleanliness.
Every year the collection of research and books on patient safety and all its component parts grows larger and larger. Patient safety has expanded to include other areas of study that can impact on the safety of patient care including; human factors, ergonomics, behavioural insights, improvement science, LEAN methodology, resilience engineering and high reliability organisations.
Those that work in patient safety have significantly raised awareness and understating of patient safety and as we have seen some aspects of harm have reduced.
We have yet to build a safety culture that is embedded into every day practice, every day actions and every individual’s mind-set. Patients are still being harmed by the same things that were happening in the year 2000.
The reason why have I chosen to reference this particular journal published in the year 2000, and less so on the thousands of articles that have been published since, is that every single article could have been written today and be describing the exact same situations we still find ourselves in and have the exact same meaning for the reader.
While it feels like so much has happened since the articles were written, at the same time it feels like nothing has happened since. To read these articles sixteen years on is extremely sobering.
This chapter provides the bridge between the last fifteen years and the next where hopefully we can narrow the implementation gap between the ideal and the real.
- Patient safety and a safety culture are a way of being
- People take the time to embed good practice so that it is sustained
- Implementation is valued as much as improvement and innovation
- We have tackled patient safety differently and have been bold enough to stop the things that are not working and started again
Leape LL, Berwick DM (2000) Safe healthcare: are we up to it? BMJ Qual Saf 320: 725-726
National Patient Safety Foundation (2015) Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human. National Patient Safety Foundation, Boston, MA; 2015 [online] available via http://www.NPSF.org