False Dawns and New Horizons in Patient Safety Research and Practice Editorial (original) (raw)
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False Dawns and New Horizons in Patient Safety Research and Practice
International journal of health policy and management, 2017
In response to a weight of evidence that patients are frequently harmed as a result of their care, there have been concerted efforts to make healthcare safer, with health systems across the globe investing significant resources in policies and programmes designed to reduce adverse events. Yet, despite extensive efforts, improvements in safety have proved difficult to sustain and spread, with studies confirming there has been no measurable, systems-level improvement in the overall rates of preventable harm. Here, we highlight the limitations of the thinking which underpins current efforts to make healthcare systems safer and point to new and emerging approaches to understanding and addressing patient safety in complex, dynamic health systems.
2018
Who could disagree with the seemingly common-sense reasoning that: " We must learn from the things that go wrong. " ? Despite major investments to improve patient safety, relatively few evaluations demonstrate convincing reductions in risk, harm, serious error or death. This disappointing trajectory of improvement from learning from errors or Safety-I as it is sometimes known has led some researchers to argue that there is more to be gained by learning from the majority of healthcare episodes: the things that go right. Based on this premise, so-called Safety-II has emerged as a new paradigm. In this commentary, we consider the ongoing value of Safety-I based approaches and explore whether now is the time to abandon learning from " the bad " and re-energise data collection and analysis by focusing on " the good. " Citation: Carson-Stevens A, Donaldson L, Sheikh A. The rise of patient Safety-II: should we give up hope on Safety-I and extracting value from patient safety incidents? Comment on " False dawns and new horizons in patient safety research and practice.
Transforming concepts in patient safety: a progress report
BMJ quality & safety, 2018
In 2009, the National Patient Safety Foundation's Lucian Leape Institute (LLI) published a paper identifying five areas of healthcare that require system-level attention and action to advance patient safety.The authors argued that to truly transform the safety of healthcare, there was a need to address medical education reform; care integration; restoring joy and meaning in work and ensuring the safety of the healthcare workforce; consumer engagement in healthcare and transparency across the continuum of care. In the ensuing years, the LLI convened a series of expert roundtables to address each concept, look at obstacles to implementation, assess potential for improvement, identify potential implementation partners and issue recommendations for action. Reports of these activities were published between 2010 and 2015. While all five areas have seen encouraging developments, multiple challenges remain. In this paper, the current members of the LLI (now based at the Institute for H...
Why patient safety is such a tough nut to crack
BMJ, 2011
It's now more than a decade since the US Institute of Medicine's landmark 1999 report To Err Is Human put patient safety prominently on the international agenda. Despite countless initiatives, publications, and conferences on the topic, improvement has been disappointingly slow. Ian Leistikow and colleagues define the four challenges that make patient safety such a tough nut to crack, and propose a way out of the impasse Ian P Leistikow coordinator of patient safety center 1 , Cor J Kalkman professor in anesthesiology; head of patient safety center 1 , Hans de Bruijn professor of public administration and management 2
2018
In their editorial, Mannion and Braithwaite contend that the approach to solving the problem of unsafe care, Safety I, is flawed and requires a shift in thinking to what they are calling Safety II. We have reservations as to whether by itself the shift from Safety I to Safety II is sufficient. Perhaps our failure to improve outcomes in the field of patient safety and quality lies less in our approach – Safety I vs. Safety II – and more in the lack of an agreed upon, commonly understood set of core competencies (knowledge, skills, and attitudes) needed in its workforce. The authors explore in this commentary the need to establish core competencies as part of the pathway to professionalism for the discipline of patient safety and quality.