In Patient Safety Now I assert that the future of patient safety requires us to do 3 things
- look at safety differently
- understand the reality of people’s working lives
- build a restorative, just and compassionate culture within a psychologically safe environment
Lets look at the first one. Look at safety differently.
Professor James Reason famously said over twenty years ago,
‘we cannot change the human condition, but we can change the conditions under which humans work’
These conditions include the working environment, the tasks and procedures that are performed, the number of people that we work alongside, the skills that we and others have, the physical, emotional and psychological conditions that impact on our ability to perform.
The conditions also apply to how safety, and the way we look at safety, impacts on the conditions under which humans work. If it is perceived as something to fear, if it is understood as solely ‘the things that go wrong’, if it is about judging people’s judgement and responding with blame and shame then this will impact negatively on the staff involved and impact on the amount we can learn.
The longstanding tradition of patient safety has been to focus on events such as falls and pressure ulcers, unsafe acts such as errors in decisions and judgement and mistakes such as administering the wrong drug to the wrong person. The people involved are often labelled as careless, negligent and reckless, assuming they are bad people. The solutions have included writing procedural documents, disciplinary measures, threats, and retraining.
Overtime this has shifted. There is a desire now to move towards the systems approach and to understand the recurrent factors in the workplace that can give rise to erroneous conditions. The focus is not on ‘who did what’ but on ‘how and why’ did the events occur, ‘what led to the decisions or judgements made’. As Reason also said.. ‘error is not the monopoly of an unfortunate few, far from being random, mishaps tend to fall into recurrent patterns. The same set of of circumstances can provoke similar errors, regardless of the people involved’.
This last sentence, the same set of circumstances can provoke similar errors, regardless of the people involved, is a fantastic starting point to try to understand how systems function (well or not so well). By combining the study of systems and the things we do within them, when they are working well and when they have failed, will provide us with a better view of what we need to tweak, what we need to strengthen, what we need to adapt or what we simply need to leave alone.
Healthcare is often talked of as the management of ill health rather than the prevention of ill health. As humans we are not always great at seeking ways to prevent illnesses or poor health; looking at what works to reduce our chances of developing diabetes, getting high blood pressure, infections, falling and so on. All too often we don’t do anything to address these things until they actually happen rather than imagining they might. We address them when they impact adversely on our health. This is the same with safety, we wait for the failure to happen before we address it. It would be wonderful if we could go upstream and see what we can do to prevent those things from happening.
Our mindset can still focus on failure but more about the potential for failure and what we can do to mitigate it rather than dealing with the actual failure. A bit like going on a long walk, ensuring we have the right clothes, checking the weather, taking along some sustenance to keep us going, having a map or way of telling us which direction to head and importantly how to get back. All of these things are preventative measures. What would that look like for the conditions under which humans work? Making sure we have the right equipment, that there is as little variation as possible to help people intuitively get it right, having the right cultural conditions that help us thrive, develop relationships, be able to talk to one another, enough food and hydration to keep us going and a few helpful rules and evidence based guidance that head us in the right direction.
This is what I mean by looking at safety differently. Making the system as robust as possible given there are a lot of human beings around and constantly learning about how we can make it a little bit better every time we look. Adapting and adjusting to unexpected situations is what we do best. This kind of safety is proactive, preventative, positive, and above all else kind.
Patient Safety Now 