Delivering safe health care: safety is a patient’s right and the obligation of all health professionals (original) (raw)
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The 'systems approach' to patient safety in healthcare has recently led to questions about its ethics and practical utility. In this viewpoint, we clarify the systems approach by examining two popular misunderstandings of it: (1) the systematisation and standardisation of practice, which reduces actor autonomy; (2) an approach that seeks explanations for success and failure outside of individual people. We argue that both giving people a procedure to follow and blaming the system when things go wrong misconstrue the systems approach.
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Healthcare systems across the world and especially those in low-resource settings (LRS) are under pressure and one of the first priorities must be to prevent any harm done while trying to deliver care. Health care workers, especially department leaders, need the diagnostic abilities to identify local safety concerns and design actions that benefit their patients. We draw on concepts from the safety sciences that are less well-known than mainstream quality improvement techniques in LRS. We use these to illustrate how to analyse the complex interactions between resources and tools, the organisation of tasks and the norms that may govern behaviours, together with the strengths and vulnerabilities of systems. All interact to influence care and outcomes. To employ these techniques leaders will need to focus on the best attainable standards of care, build trust and shift away from the blame culture that undermines improvement. Health worker education should include development of the tech...
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Patient safety is a prominent theme in health care delivery today. This should come as no surprise, given that "first, do no harm" has been the ethical watchword throughout the history of medicine, nursing, and pharmacy. In recent years, we have become increasingly aware of the magnitude of our failure to successfully live up to this ethical imperative. We have also become increasingly aware of techniques that we might employ to bring reality closer to the ideal of doing no (preventable) harm. The realization of the magnitude of this failure and that there are potential routes to reducing harm has fortunately resulted in both a burgeoning of research in the area of patient safety and a willingness to invest in patient safety research. This volume-published by the Agency for Healthcare Research and Quality (AHRQ) with support from the U.S. Department of Defense-along with its three companion volumes, is testimony to this blossoming of research and funding.
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Understanding of, and commitment to, patient safety worldwide has grown since the late 1990s. This was prompted by two influential reports: To Err is Human [1] produced by the Institute of Medicine (now called the National Academy of Medicine) in the USA and An Organisation with a Memory [2] produced by the United Kingdom Government's Chief Medical Adviser. Both reports recognised that error was routine during the delivery of healthcare: affecting something like one in ten of all hospital patients. In a proportion of cases, the outcome produced was serious, even fatal. The reports also drew attention to the poor performance of healthcare, as a sector, worldwide on safety compared to most other high-risk industries. Notably, aviation has shown remarkable and sustained improvements in the risk to passengers of air travel over four decades. Both reports called for greater focus on, and commitment to, reducing the risks of healthcare. Since then, the quest to improve the safety of care for patients has become a global movement. Important bodies like the World Health Organization (WHO) [3], the Gulf Cooperation Council (GCC) [4], the Agency for Healthcare
How safe are clinical systems?
2010
Adverse event-an unintended injury caused by medical management rather than the disease process. Reliability-the probability that a system will function correctly and, as a result, the chance that evidence based care will be provided. Failure rate-the inverse of reliability-so a 15% failure rate represents 85% reliability. Standardisation-establishing a process which always functions in the same way, with no variation. Study sites and topics is research had NHS ethics approval. Seven NHS organisations were studied and we collected data from three erent organisations for each topic.
2011
The knowledge that poor systems can cause harm is not new, but the size of this problem has not been established systematically. This report provides groundbreaking evidence of the extent to which important clinical systems and processes fail, and the potential these failings have to harm patients. This study forms part of the Health Foundation’s work to help healthcare organisations improve the quality of services they offer. Our Safer Patients Initiative has highlighted the need to take a clinical systems approach to improving safety, since it is failings in these systems that often contribute to breakdowns in patient safety.
Guidelines, judgement, opinion, and clinical experience
Quality and Safety in Health Care, 2001
Delivering safe health care: safety is a patient's right and the obligation of all health professionals* One fundamental guarantee that we cannot give our patients is that faults and errors in the healthcare system won't harm them. Of course, health care is by its nature risky. Not everyone undergoing surgery for an aortic aneurysm survives. Many interventions carry risks. But these risks are mostly small and usually quantifiable. Ideally, patients understand the possible risks and benefits before choosing to undergo a procedure. For some patients these are diYcult decisions. Although healthcare professionals may discuss risks of treatment, they do not speak about risks of harm from the system-or even about such harm when it occurs. Recent studies in the United States, Australia, and the United Kingdom and reports from the US Institute of Medicine and the UK Department of Health have drawn attention to the chronic "unsafeness" of health systems worldwide. 1-7 This attention is not new. What is new is that preventable, iatrogenic injuries are being quantified and openly discussed. For example, adverse drug reactions have become a national issue in the United States-studies show that adverse drug events occurred in 6.5% of hospitalisations. 8 These reports have highlighted the tensions between accountability and improvement, the needs of individual patients and benefit to society, and production goals and safety. Most causes-and solutions-lie in the systems of care and how we work. Healthcare professionals, however, focus energy on individual patients, tackling diYculties in the system as they appear-often as separate problems and not in parallel. Individual care is, of course, crucial but, unless attention is given to the system, our patients are at risk from a faulty service. For example, inadequate handovers can mean that vital information is lost between diVerent care givers and services. Is it that the word "system" is anathema to many healthcare professionals? Just getting health professionals to work harder or exhorting them to be safer will not help; the system of care must be redesigned. We must instil a chronic sense of unease-a constant awareness of risk in every action. 9 Such attention to risk enables crews of aircraft carriers to launch and land several planes every day on decks the size of two football fields with *This is a version of an editorial which appeared in the BMJ 2001; 323:585-6.