The Essentials of Patient Safety - Clinical Human Factors Group

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The Essentials of Patient Safety Institute, was far more wide ranging than the headline figures suggest. A large number of studies of error and harm were reviewed including the causes of harm, the nature of safe and unsafe systems and the role of leadership and regulation. The principal aim of the report was to establish patient safety as a major requirement and activity of modern healthcare, by establishing national centres and programmes, expanding and improving reporting systems and driving safety in clinical practice through the involvement of clinicians, purchasers of healthcare, regulatory agencies and the public. An organisation with a memory: learning from adverse events in the NHS Since the publication of the Institute of Medicine report many governments and professional organisations have released reports and official statements on patient safety. The British equivalent of the Institute of Medicine report was prepared by a (10). Unlike the Institute of Medicine report, it emanated from government and was bravely authorised for release by the then Secretary of State for Health Alan Milburn. Reviewing the systems of learning from errors in the NHS, the report identified numerous weaknesses with the processes and contrasted this unfavourably with other high-risk industries. Great stress was also laid on understanding the underlying causes of adverse events and on the potential parallels between healthcare and other high risk industries. The report argued that all human beings who work in complex systems are prone to similar errors and subject to similar pressures. The themes and progress on culture, teamwork, reporting, systems thinking highlighted in these reports will all be examined in later chapters. But first we need to examine the studies of the nature and scale of harm. Can it really be true that healthcare kills tens of thousands of people each year in the United States and, by implication, perhaps hundreds of thousands across the world KEY POINTS Patient safety is the avoidance, prevention and amelioration of harm from healthcare Tragedies and high profile cases have raised public awareness of patient safety Some errors cause harm but many do not Blame and discipline are an ineffective response to most safety problems Government and professional reports brought patient safety into the mainstream 8
The Essentials of Patient Safety References 1. Kohn L, Corrigan J, Donaldson ME. To err is human. Washington DC: National Academy Press; 1999. 2. Vincent C. Patient Safety, 2nd edn. Oxford: Wiley Blackwell; 2010. 3. McNutt RA, Abrams R, Aron DC, for the Patient Safety C. Patient Safety Efforts Should Focus on Medical Errors. Journal of the American Medical Association, 2002; 287(15):1997-2001. 4. Layde PM, Maas LA, Teret SP, Brasel KJ, Kuhn EM, Mercy JA, et al. Patient Safety Efforts Should Focus on Medical Injuries. Journal of the American Medical Association, 2002; 287(15):1993-7. 5. Joice P, Hanna GB, Cuschieri A. Errors enacted during endoscopic surgery - a human realiability analysis. Applied Ergonomics, 1998;29(6):409-14. 6. Cook RI, Woods DD, Miller CA. A tale of two stories: contrasting views of patient safety, US National Patient Safety Foundation 1998. 7. Walshe K, Offen N. A very public failure: lessons for quality improvement in healthcare organisations from the Bristol Royal Infirmary. Quality and Safety in Health Care, 2001;10(4):250-6. 8. Leape LL. Error in medicine. Journal of the American Medical Association, 1994;272(23):1851-7. 9. Leape LL. Institute of Medicine medical error figures are not exaggerated. Journal of the American Medical Association, 2000;284(1):95-7. 10. Department of Health. An organisation with a memory: learning from adverse events in the NHS. London: The Stationery Office; 2000. 9
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