Dynamics of dignity and safety: a discussion (original) (raw)
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Asia Pacific Journal of Health Management (APJHM), 2015
This review article demonstrates the causal relationship between a poor safety and quality culture in Australian and overseas hospitals and the occurrence of adverse patient events (AEs). The evidence of serious adverse events occurring in these hospitals is unquestionable. Awareness of the importance of that poor safety and quality culture in hospitals and its linkage with AEs is not as widespread as is warranted, but there is mounting evidence of its rapidly increasing recognition. The concept of technical and non-technical competence in workers in different industries is also well developed, with an increasing consensus that the non-technical aspects of healthcare delivery are responsible for a majority of the adverse events, rather than issues of technical competence. The need to provide patient safety education, particularly in a multi-professional setting has been established through the World Health Organisation’s (WHO) Patient Safety Curriculum Guide: Multi- Professional Edition in 2011. This document also stresses the importance of multi-disciplinary care teams. A corollary of this is the need to extend this education to more senior members of healthcare teams, who did not experience these concepts in their education. Following completion of the education of those senior members in the issues of a safety and quality culture, all members of those professions must then have periodic mandatory reviews of these lessons incorporated into their continuing professional development (CPD) activities. One manifestation of that poor safety and quality culture is bullying, which is extensive in hospitals and which is rapidly being recognised in the Australian environment.
What's in a name? On the nuance of language in patient safety
British Journal of Anaesthesia, 2019
In 2001, the BMJ decided to ban the term 'accident' and start using proper descriptions of the actual incident (e.g. car collision or rollover rather than 'road traffic accident'). 1 This was based on the rationale that most events are 'predictable and preventable' rather than 'acts of God', as the former term suggests. Thus, the term 'medical error' was introduced to account for everything that goes wrong in the healthcare system. Over the years, error has taken on many forms: it has been individual and systemic, intentional or unintentional, medical or surgical, blamed on human frailty (or a variety of other things), underreported, oversimplified, admitted or hidden, and of course measured. But most importantly, it remains a retrospective attribution that does little to explain the local rationality of those involved when the 'error' happened. 2 Healthcare professionals do their best to diagnose and treat all types of medical problems in the patients they care for. But in spite of hard work and good intentions, some patients do experience harm, sometimes with deadly results. These situations are devastating to patients and their relatives, while also affecting the healthcare personnel involved. Over the past two decades, the number of publications on these problems has steadily increased, with a strong emphasis on learning and subsequent risk reduction. As evidenced by the recent debate around the term 'second victim', 3 the use of language can greatly influence the safety discourse, especially after an adverse event has occurred. The way we choose to describe the event, in an attempt to reconstruct the messy convolution of factors that comprise everyday work, is of more importance than what we initially may realise. Although commonly used in this context, the notion of 'medical error' or 'human error' is problematic in any description of an adverse event. It is a label applied in hindsight, after a multitude of facts has been logically examined in an attempt of sensemaking. It can conveniently metamorphose to explain almost any undesired event, 2 thereby simplifying the complexity of how the actual work is
The Reform of Health Care, 2012
This paper examines the concept of patient safety and attempts to unravel its inherent complexity by examining the perceptions of a range NHS managers and professionals. It draws from one strand of a NIHR SDO commissioned study which employed qualitative methods to explore understanding of cultural and broader contextual influences on patient safety and staff well-being performance in eight English NHS Trusts. 144 staff in 8 NHS acute Trusts were interviewed and observations were also conducted of relevant meetings. A comparative case strategy was adopted. The paper identifies how Trust staff reported highly varied meanings and understanding of what constitutes safety and risk; often struggling to find a common language or interpretation; and simultaneously undertaking many routine and tacit safety promoting practices as well and encountering many perceived barriers to delivering or ensuring patient safety. Staff made clear indirect or direct connections between their own well-being and patient safety. The data also reveal perceived system and conceptual weaknesses with few examples of integrated or connected patient safety systems which link to overall governance; clinical governance, complaints, risk analysis, incident reporting, or human resource management. Theories from change and health care management and organisational behaviour and sociology are used to make a case for better understanding and documenting of everyday care practices both overt and tacit and contexts, as well as marrying up these micro realities with a more holistic awareness of organisational level governance, risks and structures. It is argued that patient safety research and consequently evidence informed interventions will benefit from adopting both ethnographic and processual research strategies and traditions.
Patient safety and health policy: a history and review
Hematology-oncology Clinics of North America, 2002
The safety movement in health care, however, can be described as being dormant for many decades, with explosive interest and growth beginning in the mid-1990s. Although "first do no harm" has always been a primary guiding principle for physicians, there are many legal, cultural, logistic, and other barriers to obtaining an honest appraisal of the extent of preventable patient injuries and doing something about the understanding gained. A number of forces converged in the past 15 years to break down these barriers and question long-standing taboos. These forces include a relentless drive for cost containment by payors, changes in social mores that are moving decision-making authority to patients and groups of stakeholders (ie, away from the traditional paternalistic, physician-driven model), easily available information to all on the Internet, and an emboldened media that has kept celebrated cases of gross mishaps on the front pages. In addition, several relatively recent large epidemiologic studies of harm due to medical management have been picked up by the popular press and replicated in other industrialized countries with similar findings. Despite imperfect methodologies, the studies portray an unacceptable picture of a huge cottage industry that is morally and fiscally irresponsible.
Patient safety – an old and a new issue
Theoretical Issues in Ergonomics Science, 2007
Patient safety-an old and a new issue 1. A bit of history Today, patient safety is considered as one of the most prominent issues in healthcare. Mass media very often insist upon it. Medical malpractices, adverse events in hospitals, human medical errors and their negative outcomes have become hot topics in magazines, newspapers and TV worldwide. The large press coverage and the diffusion of people's concerns have been developed quite recently; say, no more than 10 years ago. Consequently, patient safety is often, though wrongly, perceived as a new issue and, somehow, this perception corresponds to the reality. Indeed, patient safety is rooted in the practice and theory of medicine from its very origin. Every healthcare professional knows Hippocrates' principle: 'primum non nocere' (first, do no harm). The ethics and practice of every physician should be (and, hopefully, are) based on this principle. However, though embedded since the early days in the medical profession, patient safety was not of much concern for the people, notwithstanding they, sooner or later, inevitably, become patients. Although cases of supposed malpractice (and, sometimes, of severe punishments of wrongdoers) were frequently reported during the centuries, the awareness that medical professional activity might actually harm patients was practically unknown until the 19th century. Indeed, in 1867, Florence Nightingale, the founder of nursing science, in Notes on hospital, reported that: '.. . the actual mortality in hospitals, especially in those of large crowded cities, is very much higher than any calculation founded on the mortality of the same class of diseases among patient treated out of hospitals lead us to expect' (quoted from Vincent 2006, p. 3). Some years earlier, Ignaz Philipp Semmelweis had already confirmed this statement by discovering that puerperal fever was caused by infecting particles on the hands of medical students and doctors contaminated in the autopsy room. His observations went against current scientific opinion, not to say, the opinion of medical doctors, who were not at all eager to admit that they caused many deaths. As one may notice, however, the issue of patient safety was still debated among healthcare professionals. The general public, in those years (and for many years to come) was more fascinated by the successes and discoveries in medicine, rather than by its faults.
Human Error and Patient Safety
Textbook of Patient Safety and Clinical Risk Management, 2020
This chapter introduces the topic of error as an essential foundation for an understanding of patient safety. We introduce psychological classifications of error and then, using clinical examples, show how we can use these ideas to understand how errors occur and how chains of small errors can combine to cause harm to patients. We outline a practical approach to conducting investigations into healthcare incidents. Finally, we offer some reflections on how doctors experience errors and how best to support yourself or your colleagues when things do not go as well as intended.